Jacqueline Posada, MD

Medical school clinical rotations are a rite of passage as students emerge from their basic science courses and first board exam to the clinical world where the patients vaguely resemble the question stem descriptions. Finally, intangible theory can be put into practice. Yet, it is becoming increasingly difficult for 3rd-year medical student clerkship directors to find enough clinical sites to support the growing number of medical students as enrollment numbers steadily increase and outpace the current clinical resources.

In a 2019 Association of American Medical Colleges report, 84% of medical school deans were concerned about the diminishing number of clerkship sites, and there was additional worry about lack of qualified specialty preceptors. This lack of clerkship availability is especially true for psychiatry sites.

Psychiatry clerkship directors are in need of more clinical sites to address the educational needs of medical students, and psychiatrists in the broader clinical community are positioned to help medical schools expand their clinical sites.

Inpatient psychiatric units and consult services continue to be popular sites for medical student rotations, but it has been hard to expand into other settings, where psychiatric treatment is seen as more private and intimate than other specialties. Reasons for falling site availability are varied and include 1) financial disincentive to take students – because they can be seen as a burden on supervisors who must meet revenue-generating patient quotas; 2) competition with other learners, including residents, PA students, NPs, and NP students; and 3) the general financial and operational obstacles to clinical practice inflicted by the pandemic. COVID-19 affected medical education – for better and worse (JAMA. 2020;324[11]:1033-4). Psychiatry clerkships particularly suffered from restricted patient access as inpatient units reduced their census to comply with COVID-19 safety protocols, and during the height of the pandemic inpatient units provided psychiatric care to COVID-19–positive patients, which precluded student involvement. On the other hand, many more students were introduced to telepsychiatry and witnessed creative forms of mental health intervention as clinicians adapted their practices to the pandemic.
 

When rotations began

Clinical rotations entered the American medical school curriculum in the 1890s when Sir William Osler brought the European standard of medical education with him as Physician in Chief at the newly opened Johns Hopkins University Hospital. He formalized the traditional apprenticeship model by standardizing 3rd- and 4th-year clerkships as rotations in which medical students worked in clinics and on the wards, learning from residents and attendings.

Clinical rotations, their location, the supervisors, and the patients and their ailments all go in to influence a student’s specialty choice. Some students enter medical school knowing they want to be a surgeon, a pediatrician, or a psychiatrist. And some are compelled by a specific rotation, when they realize that it’s not at all what they expected and maybe they could dedicate their professional life to this area of medicine.

High-quality clinical clerkship sites are essential to the future of psychiatry. At clerkship sites, undecided students interested in psychiatry may affirm their commitment to psychiatry. Other students will have their only dedicated exposure to psychiatrically ill patients. This represents students’ only opportunity to learn the skills to treat comorbid psychiatric and medical illness. Regardless of specialty, nearly every physician will have to treat patients with some psychiatric illnesses.

What constitutes a “high-quality clinical site” is difficult to measure and define. Some measures of quality include a safe learning environment, a reasonable ratio of students to supervisors (including residents, fellows, and attendings), and an adequate number and diversity of patients. Many medical schools may prefer an affiliated academic medical center or Veterans’ Affairs hospitals for their rotating students. Private psychiatric hospitals are proliferating, and if these are to be sites for medical students, the following standards are suggested: Private psychiatric hospitals must follow standard safety precautions with sufficient staff presence, ensure willing preceptors who can provide adequate student supervision, and adjust their expectations to students who can carry a few patients of diverse background, but are not to be treated merely as scribes.

Psychiatrists, whether they consider themselves “academic” or not, have a role to play in expanding access to clinical sites. Students are eager to learn in any setting. Inpatient settings have long been seen as the norm for clinical education in psychiatry. Yet inpatient settings perpetuate the idea that those with severe mental illness or individuals with psychosocial stressors or disabling, comorbid substance use disorders are the only people who seek help from a psychiatrist. This article is a call to action to our colleagues in community mental health centers, managed care settings, and other psychiatric treatment providers without an academic affiliation to explore the possibility of creating space for a medical student in their clinical practice.

We cannot deny the demands on psychiatrists’ time – every minute is counted by the patient and doctor, and every encounter is accounted for in some revenue stream. However, the academic world is running out of space for its students, and there’s a serious question as to whether an academic center is the only place for students. If you are a psychiatrist who still loves to learn and prides themselves on high-quality patient care, then you have an essential role in shaping the students who will one day be your peers in psychiatry, or the physicians treating your patients’ comorbid medical illnesses.

There are upfront challenges to teaching 3rd-year medical students, including teaching the psychiatric interview, note writing, persuading patients to allow students into their care, and setting time aside at the end of the workday to provide feedback on performance. Yet, after learning the ropes of psychiatric patient care, medical students can provide help in writing notes, calling collateral, contacting patients with their laboratory results, and even helping with the tedious but necessary administrative tasks like prior authorizations. In exchange for training students, some medical schools may offer perks, such as a volunteer faculty position that comes with access to usually expensive library resources, such as medical databases.

You can help expand clinical sites in psychiatry rotations by contacting your alma mater or the medical school closest to your community and asking about their need for clerkship sites. Many medical schools are branching out by sending students to stay near the clinical sites and immerse themselves in the community where their site director practices. Even one-half day a week in an outpatient setting provides patient and setting diversity to students and helps spread out students to different sites, easing the burden on inpatient supervisors while providing students more individualized supervision.

The practice of medicine is built on apprenticeship and teaching wisdom through patient care. Just because we leave residency doesn’t mean we leave academics. Taking students into your practice is an invaluable service to the medical education community and future physicians.
 

Dr. Posada is assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington, and staff physician at George Washington Medical Faculty Associates, also in Washington. She has no conflicts of interest. Dr. Ortiz is assistant professor and clerkship director in the department of psychiatry at Texas Tech University Health Sciences Center – El Paso. She has no conflicts of interest.

Medical school clinical rotations are a rite of passage as students emerge from their basic science courses and first board exam to the clinical world where the patients vaguely resemble the question stem descriptions. Finally, intangible theory can be put into practice. Yet, it is becoming increasingly difficult for 3rd-year medical student clerkship directors to find enough clinical sites to support the growing number of medical students as enrollment numbers steadily increase and outpace the current clinical resources.

In a 2019 Association of American Medical Colleges report, 84% of medical school deans were concerned about the diminishing number of clerkship sites, and there was additional worry about lack of qualified specialty preceptors. This lack of clerkship availability is especially true for psychiatry sites.

Psychiatry clerkship directors are in need of more clinical sites to address the educational needs of medical students, and psychiatrists in the broader clinical community are positioned to help medical schools expand their clinical sites.

Inpatient psychiatric units and consult services continue to be popular sites for medical student rotations, but it has been hard to expand into other settings, where psychiatric treatment is seen as more private and intimate than other specialties. Reasons for falling site availability are varied and include 1) financial disincentive to take students – because they can be seen as a burden on supervisors who must meet revenue-generating patient quotas; 2) competition with other learners, including residents, PA students, NPs, and NP students; and 3) the general financial and operational obstacles to clinical practice inflicted by the pandemic. COVID-19 affected medical education – for better and worse (JAMA. 2020;324[11]:1033-4). Psychiatry clerkships particularly suffered from restricted patient access as inpatient units reduced their census to comply with COVID-19 safety protocols, and during the height of the pandemic inpatient units provided psychiatric care to COVID-19–positive patients, which precluded student involvement. On the other hand, many more students were introduced to telepsychiatry and witnessed creative forms of mental health intervention as clinicians adapted their practices to the pandemic.
 

When rotations began

Clinical rotations entered the American medical school curriculum in the 1890s when Sir William Osler brought the European standard of medical education with him as Physician in Chief at the newly opened Johns Hopkins University Hospital. He formalized the traditional apprenticeship model by standardizing 3rd- and 4th-year clerkships as rotations in which medical students worked in clinics and on the wards, learning from residents and attendings.

Clinical rotations, their location, the supervisors, and the patients and their ailments all go in to influence a student’s specialty choice. Some students enter medical school knowing they want to be a surgeon, a pediatrician, or a psychiatrist. And some are compelled by a specific rotation, when they realize that it’s not at all what they expected and maybe they could dedicate their professional life to this area of medicine.

High-quality clinical clerkship sites are essential to the future of psychiatry. At clerkship sites, undecided students interested in psychiatry may affirm their commitment to psychiatry. Other students will have their only dedicated exposure to psychiatrically ill patients. This represents students’ only opportunity to learn the skills to treat comorbid psychiatric and medical illness. Regardless of specialty, nearly every physician will have to treat patients with some psychiatric illnesses.

What constitutes a “high-quality clinical site” is difficult to measure and define. Some measures of quality include a safe learning environment, a reasonable ratio of students to supervisors (including residents, fellows, and attendings), and an adequate number and diversity of patients. Many medical schools may prefer an affiliated academic medical center or Veterans’ Affairs hospitals for their rotating students. Private psychiatric hospitals are proliferating, and if these are to be sites for medical students, the following standards are suggested: Private psychiatric hospitals must follow standard safety precautions with sufficient staff presence, ensure willing preceptors who can provide adequate student supervision, and adjust their expectations to students who can carry a few patients of diverse background, but are not to be treated merely as scribes.

Psychiatrists, whether they consider themselves “academic” or not, have a role to play in expanding access to clinical sites. Students are eager to learn in any setting. Inpatient settings have long been seen as the norm for clinical education in psychiatry. Yet inpatient settings perpetuate the idea that those with severe mental illness or individuals with psychosocial stressors or disabling, comorbid substance use disorders are the only people who seek help from a psychiatrist. This article is a call to action to our colleagues in community mental health centers, managed care settings, and other psychiatric treatment providers without an academic affiliation to explore the possibility of creating space for a medical student in their clinical practice.

We cannot deny the demands on psychiatrists’ time – every minute is counted by the patient and doctor, and every encounter is accounted for in some revenue stream. However, the academic world is running out of space for its students, and there’s a serious question as to whether an academic center is the only place for students. If you are a psychiatrist who still loves to learn and prides themselves on high-quality patient care, then you have an essential role in shaping the students who will one day be your peers in psychiatry, or the physicians treating your patients’ comorbid medical illnesses.

There are upfront challenges to teaching 3rd-year medical students, including teaching the psychiatric interview, note writing, persuading patients to allow students into their care, and setting time aside at the end of the workday to provide feedback on performance. Yet, after learning the ropes of psychiatric patient care, medical students can provide help in writing notes, calling collateral, contacting patients with their laboratory results, and even helping with the tedious but necessary administrative tasks like prior authorizations. In exchange for training students, some medical schools may offer perks, such as a volunteer faculty position that comes with access to usually expensive library resources, such as medical databases.

You can help expand clinical sites in psychiatry rotations by contacting your alma mater or the medical school closest to your community and asking about their need for clerkship sites. Many medical schools are branching out by sending students to stay near the clinical sites and immerse themselves in the community where their site director practices. Even one-half day a week in an outpatient setting provides patient and setting diversity to students and helps spread out students to different sites, easing the burden on inpatient supervisors while providing students more individualized supervision.

The practice of medicine is built on apprenticeship and teaching wisdom through patient care. Just because we leave residency doesn’t mean we leave academics. Taking students into your practice is an invaluable service to the medical education community and future physicians.
 

Dr. Posada is assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington, and staff physician at George Washington Medical Faculty Associates, also in Washington. She has no conflicts of interest. Dr. Ortiz is assistant professor and clerkship director in the department of psychiatry at Texas Tech University Health Sciences Center – El Paso. She has no conflicts of interest.

Medical school clinical rotations are a rite of passage as students emerge from their basic science courses and first board exam to the clinical world where the patients vaguely resemble the question stem descriptions. Finally, intangible theory can be put into practice. Yet, it is becoming increasingly difficult for 3rd-year medical student clerkship directors to find enough clinical sites to support the growing number of medical students as enrollment numbers steadily increase and outpace the current clinical resources.

In a 2019 Association of American Medical Colleges report, 84% of medical school deans were concerned about the diminishing number of clerkship sites, and there was additional worry about lack of qualified specialty preceptors. This lack of clerkship availability is especially true for psychiatry sites.

Psychiatry clerkship directors are in need of more clinical sites to address the educational needs of medical students, and psychiatrists in the broader clinical community are positioned to help medical schools expand their clinical sites.

Inpatient psychiatric units and consult services continue to be popular sites for medical student rotations, but it has been hard to expand into other settings, where psychiatric treatment is seen as more private and intimate than other specialties. Reasons for falling site availability are varied and include 1) financial disincentive to take students – because they can be seen as a burden on supervisors who must meet revenue-generating patient quotas; 2) competition with other learners, including residents, PA students, NPs, and NP students; and 3) the general financial and operational obstacles to clinical practice inflicted by the pandemic. COVID-19 affected medical education – for better and worse (JAMA. 2020;324[11]:1033-4). Psychiatry clerkships particularly suffered from restricted patient access as inpatient units reduced their census to comply with COVID-19 safety protocols, and during the height of the pandemic inpatient units provided psychiatric care to COVID-19–positive patients, which precluded student involvement. On the other hand, many more students were introduced to telepsychiatry and witnessed creative forms of mental health intervention as clinicians adapted their practices to the pandemic.
 

When rotations began

Clinical rotations entered the American medical school curriculum in the 1890s when Sir William Osler brought the European standard of medical education with him as Physician in Chief at the newly opened Johns Hopkins University Hospital. He formalized the traditional apprenticeship model by standardizing 3rd- and 4th-year clerkships as rotations in which medical students worked in clinics and on the wards, learning from residents and attendings.

Clinical rotations, their location, the supervisors, and the patients and their ailments all go in to influence a student’s specialty choice. Some students enter medical school knowing they want to be a surgeon, a pediatrician, or a psychiatrist. And some are compelled by a specific rotation, when they realize that it’s not at all what they expected and maybe they could dedicate their professional life to this area of medicine.

High-quality clinical clerkship sites are essential to the future of psychiatry. At clerkship sites, undecided students interested in psychiatry may affirm their commitment to psychiatry. Other students will have their only dedicated exposure to psychiatrically ill patients. This represents students’ only opportunity to learn the skills to treat comorbid psychiatric and medical illness. Regardless of specialty, nearly every physician will have to treat patients with some psychiatric illnesses.

What constitutes a “high-quality clinical site” is difficult to measure and define. Some measures of quality include a safe learning environment, a reasonable ratio of students to supervisors (including residents, fellows, and attendings), and an adequate number and diversity of patients. Many medical schools may prefer an affiliated academic medical center or Veterans’ Affairs hospitals for their rotating students. Private psychiatric hospitals are proliferating, and if these are to be sites for medical students, the following standards are suggested: Private psychiatric hospitals must follow standard safety precautions with sufficient staff presence, ensure willing preceptors who can provide adequate student supervision, and adjust their expectations to students who can carry a few patients of diverse background, but are not to be treated merely as scribes.

Psychiatrists, whether they consider themselves “academic” or not, have a role to play in expanding access to clinical sites. Students are eager to learn in any setting. Inpatient settings have long been seen as the norm for clinical education in psychiatry. Yet inpatient settings perpetuate the idea that those with severe mental illness or individuals with psychosocial stressors or disabling, comorbid substance use disorders are the only people who seek help from a psychiatrist. This article is a call to action to our colleagues in community mental health centers, managed care settings, and other psychiatric treatment providers without an academic affiliation to explore the possibility of creating space for a medical student in their clinical practice.

We cannot deny the demands on psychiatrists’ time – every minute is counted by the patient and doctor, and every encounter is accounted for in some revenue stream. However, the academic world is running out of space for its students, and there’s a serious question as to whether an academic center is the only place for students. If you are a psychiatrist who still loves to learn and prides themselves on high-quality patient care, then you have an essential role in shaping the students who will one day be your peers in psychiatry, or the physicians treating your patients’ comorbid medical illnesses.

There are upfront challenges to teaching 3rd-year medical students, including teaching the psychiatric interview, note writing, persuading patients to allow students into their care, and setting time aside at the end of the workday to provide feedback on performance. Yet, after learning the ropes of psychiatric patient care, medical students can provide help in writing notes, calling collateral, contacting patients with their laboratory results, and even helping with the tedious but necessary administrative tasks like prior authorizations. In exchange for training students, some medical schools may offer perks, such as a volunteer faculty position that comes with access to usually expensive library resources, such as medical databases.

You can help expand clinical sites in psychiatry rotations by contacting your alma mater or the medical school closest to your community and asking about their need for clerkship sites. Many medical schools are branching out by sending students to stay near the clinical sites and immerse themselves in the community where their site director practices. Even one-half day a week in an outpatient setting provides patient and setting diversity to students and helps spread out students to different sites, easing the burden on inpatient supervisors while providing students more individualized supervision.

The practice of medicine is built on apprenticeship and teaching wisdom through patient care. Just because we leave residency doesn’t mean we leave academics. Taking students into your practice is an invaluable service to the medical education community and future physicians.
 

Dr. Posada is assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington, and staff physician at George Washington Medical Faculty Associates, also in Washington. She has no conflicts of interest. Dr. Ortiz is assistant professor and clerkship director in the department of psychiatry at Texas Tech University Health Sciences Center – El Paso. She has no conflicts of interest.

CASE Sluggish, weak, and incoherent

Mr. O, age 24, who has a history of schizophrenia and obesity, presents to the emergency department (ED) for altered mental status (AMS). His mother reports that he has been sluggish, weak, incoherent, had no appetite, and that on the day before admission, he was drinking excessive amounts of water and urinating every 10 minutes.

HISTORY Multiple ineffective antipsychotics

Mr. O was diagnosed with schizophrenia at age 21 and struggled with medication adherence, which resulted in multiple hospitalizations for stabilization. Trials of haloperidol, risperidone, paliperidone palmitate, and valproic acid had been ineffective. At the time of admission, his psychotropic medication regimen is fluphenazine decanoate, 25 mg injection every 2 weeks; clozapine, 50 mg/d; lithium carbonate, 300 mg twice a day; benztropine, 2 mg every night; and trazodone, 50 mg every night.

EVALUATION Fever, tachycardia, and diabetic ketoacidosis

Upon arrival to the ED, Mr. O is obtunded, unable to follow commands, and does not respond to painful stimuli. On physical exam, he has a fever of 38.4°C (reference range 35.1°C to 37.9°C); tachycardia with a heart rate of 142 beats per minute (bpm) (reference range 60 to 100); tachypnea with a respiratory rate of 35 breaths per minute (reference range 12 to 20); a blood pressure of 116/76 mmHg (reference range 90/60 to 130/80); and hypoxemia with an oxygen saturation of 90% on room air (reference range 94% to 100%).

Mr. O is admitted to the hospital and his laboratory workup indicates diabetic ketoacidosis (DKA), with a glucose of 1,700 mg/dL; anion gap of 30 (reference range 4 to 12 mmol/L); pH 7.04 (reference range 7.32 to 7.42); serum bicarbonate 6 (reference range 20 to 24 mEq/L); beta-hydroxybutyrate 11.04 (reference range 0 to 0.27 mmol/L); urine ketones, serum osmolality 407 (reference range 280 to 300 mOsm/kg); and an elevated white blood cell count of 18.4 (reference range 4.5 to 11.0 × 10⁹/L). A CT scan of the head is negative for acute pathology.

Initially, all psychotropic medications are held. On Day 3 of hospitalization, psychiatry is consulted and clozapine, 50 mg/d; lithium, 300 mg/d; and benztropine, 1 mg at night, are restarted; however, fluphenazine decanoate and trazodone are held. The team recommends IV haloperidol, 2 mg as needed for agitation; however, it is never administered.

Imaging rules out deep vein thrombosis, cardiac dysfunction, and stroke, but a CT chest scan is notable for bilateral lung infiltrates, which suggests aspiration pneumonia.

Mr. O is diagnosed with diabetes, complicated by DKA, and is treated in the intensive care unit (ICU). Despite resolution of the DKA, he remains altered with fever and tachycardia.

Continue to: On Day 6 of hospitalization...

On Day 6 of hospitalization, Mr. O continues to be tachycardic and obtunded with nuchal rigidity. The team decides to transfer Mr. O to another hospital for a higher level of care and continued workup of his persistent AMS.

Immediately upon arrival at the second hospital, infectious disease and neurology teams are consulted for further evaluation. Mr. O’s AMS continues despite no clear signs of infection or other neurologic insults.

[polldaddy:10930631]

The authors’ observations

Based on Mr. O’s psychiatric history and laboratory results, the first medical team concluded his initial AMS was likely secondary to DKA; however, the AMS continued after the DKA resolved. At the second hospital, Mr. O’s treatment team continued to dig for answers.

EVALUATION Exploring the differential diagnosis

At the second hospital, Mr. O is admitted to the ICU with fever (37.8°C), tachycardia (120 bpm), tachypnea, withdrawal from painful stimuli, decreased reflexes, and muscle rigidity, including clenched jaw. The differential diagnoses include meningitis, sepsis from aspiration pneumonia, severe metabolic encephalopathy with prolonged recovery, central pontine myelinolysis, anoxic brain injury, and subclinical seizures.

Empiric vancomycin, 1.75 g every 12 hours; ceftriaxone, 2 g/d; and acyclovir, 900 mg every 8 hours are started for meningoencephalitis, and all psychotropic medications are discontinued. Case reports have documented a relationship between hyperglycemic hyperosmolar syndrome (HHS) and malignant hyperthermia in rare cases¹; however, HHS is ruled out based on Mr. O’s laboratory results.A lumbar puncture and imaging rules out CNS infection. Antibiotic treatment is narrowed to ampicillin-sulbactam due to Mr. O’s prior CT chest showing concern for aspiration pneumonia. An MRI of the brain rules out central pontine myelinolysis, acute stroke, and anoxic brain injury, and an EEG shows nonspecific encephalopathy. On Day 10 of hospitalization, a neurologic exam shows flaccid paralysis and bilateral clonus, and Mr. O is mute. On Day 14 of hospitalization, his fever resolves, and his blood cultures are negative. On Day 15 of hospitalization, Mr. O’s creatine kinase (CK) level is elevated at 1,308 U/L (reference range 26 to 192 U/L), suggesting rhabdomyolysis.

Continue to: Given the neurologic exam findings...

Given the neurologic exam findings, and the limited evidence of infection, the differential diagnosis for Mr. O’s AMS is broadened to include catatonia, neuroleptic malignant syndrome (NMS), serotonin syndrome, and autoimmune encephalitis. The psychiatry team evaluates Mr. O for catatonia. He scores 14 on the Bush-Francis Catatonia Rating Scale, with findings of immobility/stupor, mutism, staring, autonomic instability, and withdrawal indicating the presence of catatonia.²

The authors’ observations

When Mr. O was transferred to the second hospital, the primary concern was to rule out meningitis due to his unstable vitals, obtunded mental state, and nuchal rigidity. A comprehensive infectious workup, including lumbar puncture, was imperative because infection can not only lead to AMS, but also precipitate episodes of DKA. Mr. O’s persistently abnormal vital signs indicated an underlying process may have been missed by focusing on treating DKA.

TREATMENT Finally, the diagnosis is established

A lorazepam challenge is performed, and Mr. O receives 4 mg of lorazepam over 24 hours with little change in his catatonia symptoms. Given his persistent fever, tachycardia, and an elevated CK levels in the context of recent exposure to antipsychotic medications, Mr. O is diagnosed with NMS (Table 1^3,4 ) and is started on bromocriptine, 5 mg 3 times daily.

[polldaddy:10930632]

The authors’ observations

Mr. O’s complicated medical state—starting with DKA, halting the use of antipsychotic medications, and the suspicion of catatonia due to his history of schizophrenia—all distracted from the ultimate diagnosis of NMS as the cause of his enduring AMS and autonomic instability. Catatonia and NMS have overlapping symptomatology, including rigidity, autonomic instability, and stupor, which make the diagnosis of either condition complicated. A positive lorazepam test to diagnose catatonia is defined as a marked reduction in catatonia symptoms (typically a 50% reduction) as measured on a standardized rating scale.⁵ However, a negative lorazepam challenge does not definitely rule out catatonia because some cases are resistant to benzodiazepines.⁶

NMS risk factors relevant in this case include male sex, young age, acute medical illness, dehydration, and exposure to multiple psychotropic medications, including 2 antipsychotics, clozapine and fluphenazine.⁷ DKA is especially pertinent due to its acute onset and cause of significant dehydration. NMS can occur at any point of antipsychotic exposure, although the risk is highest during the initial weeks of treatment and during dosage changes. Unfortunately, Mr. O’s treatment team was unable to determine whether his medication had been recently changed, so it is not known what role this may have played in the development of NMS. Although first-generation antipsychotics are considered more likely to cause NMS, second-generation antipsychotics (SGAs) dominate the treatment of schizophrenia and bipolar disorder, and these medications also can cause NMS.⁸ As occurred in this case, long-acting injectable antipsychotics can be easily forgotten when not administered in the hospital, and their presence in the body persists for weeks. For example, the half-life of fluphenazine decanoate is approximately 10 days, and the half-life of haloperidol decanoate is 21 days.⁹

Continue to: OUTCOME Improvement with bromocriptine

After 4 days of bromocriptine, 5 mg 3 times daily, Mr. O is more alert, able to say “hello,” and can follow 1-step commands. By Day 26 of hospitalization, his CK levels decrease to 296 U/L, his CSF autoimmune panel is negative, and he is able to participate in physical therapy. After failing multiple swallow tests, Mr. O requires a percutaneous endoscopic gastrostomy (PEG) tube. He is discharged from the hospital to a long-term acute care facility with the plan to taper bromocriptine and restart a psychotropic regimen with his outpatient psychiatrist. At the time of discharge, he is able to sit at the edge of the bed independently, state his name, and respond to questions with multiple-word answers.

[polldaddy:10930633]

The authors’ observations

The most common pharmacologic treatments for NMS are dantrolene, bromocriptine, benzodiazepines (lorazepam or diazepam), and amantadine.³ Mild cases of NMS should be treated with discontinuation of all antipsychotics, supportive care, and benzodiazepines.³ Bromocriptine or amantadine are more appropriate for moderate cases and dantrolene for severe cases of NMS.³ All antipsychotics should be discontinued while a patient is experiencing an episode of NMS; however, once the NMS has resolved, clinicians must thoroughly evaluate the risks and benefits of restarting antipsychotic medication. After a patient has experienced an episode of NMS, clinicians generally should avoid prescribing the agent(s) that caused NMS and long-acting injections, and slowly titrate a low-potency SGA such as quetiapine.¹⁰Table 2^3,11,12 outlines the pharmacologic treatment of NMS.

Bottom Line

Neuroleptic malignant syndrome (NMS) should always be part of the differential diagnosis in patients with mental illness and altered mental status. The risk of NMS is especially high in patients with acute medical illness and exposure to antipsychotic medications.

Related Resource

• Turner AH, Kim JJ, McCarron RM. Differentiating serotonin syndrome and neuroleptic malignant syndrome. Current Psychiatry. 2019;18(2):30-36.

Drug Brand Names

Acyclovir • Zovirax
Amantadine • Gocovri
Ampicillin-sulbactam • Unasyn
Aripiprazole • Abilify Maintena
Benztropine • Cogentin
Bromocriptine • Cycloset, Parlodel
Ceftriaxone • Rocephin
Clozapine • Clozaril
Dantrolene • Dantrium
Diazepam • Valium
Haloperidol • Haldol
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Paliperidone palmitate • Invega Sustenna
Quetiapine • Seroquel
Risperidone • Risperdal
Valproate sodium • Depakote
Trazodone • Oleptro
Vancomycin • Vancocin

CASE Sluggish, weak, and incoherent

Mr. O, age 24, who has a history of schizophrenia and obesity, presents to the emergency department (ED) for altered mental status (AMS). His mother reports that he has been sluggish, weak, incoherent, had no appetite, and that on the day before admission, he was drinking excessive amounts of water and urinating every 10 minutes.

HISTORY Multiple ineffective antipsychotics

Mr. O was diagnosed with schizophrenia at age 21 and struggled with medication adherence, which resulted in multiple hospitalizations for stabilization. Trials of haloperidol, risperidone, paliperidone palmitate, and valproic acid had been ineffective. At the time of admission, his psychotropic medication regimen is fluphenazine decanoate, 25 mg injection every 2 weeks; clozapine, 50 mg/d; lithium carbonate, 300 mg twice a day; benztropine, 2 mg every night; and trazodone, 50 mg every night.

EVALUATION Fever, tachycardia, and diabetic ketoacidosis

Upon arrival to the ED, Mr. O is obtunded, unable to follow commands, and does not respond to painful stimuli. On physical exam, he has a fever of 38.4°C (reference range 35.1°C to 37.9°C); tachycardia with a heart rate of 142 beats per minute (bpm) (reference range 60 to 100); tachypnea with a respiratory rate of 35 breaths per minute (reference range 12 to 20); a blood pressure of 116/76 mmHg (reference range 90/60 to 130/80); and hypoxemia with an oxygen saturation of 90% on room air (reference range 94% to 100%).

Mr. O is admitted to the hospital and his laboratory workup indicates diabetic ketoacidosis (DKA), with a glucose of 1,700 mg/dL; anion gap of 30 (reference range 4 to 12 mmol/L); pH 7.04 (reference range 7.32 to 7.42); serum bicarbonate 6 (reference range 20 to 24 mEq/L); beta-hydroxybutyrate 11.04 (reference range 0 to 0.27 mmol/L); urine ketones, serum osmolality 407 (reference range 280 to 300 mOsm/kg); and an elevated white blood cell count of 18.4 (reference range 4.5 to 11.0 × 10⁹/L). A CT scan of the head is negative for acute pathology.

Initially, all psychotropic medications are held. On Day 3 of hospitalization, psychiatry is consulted and clozapine, 50 mg/d; lithium, 300 mg/d; and benztropine, 1 mg at night, are restarted; however, fluphenazine decanoate and trazodone are held. The team recommends IV haloperidol, 2 mg as needed for agitation; however, it is never administered.

Imaging rules out deep vein thrombosis, cardiac dysfunction, and stroke, but a CT chest scan is notable for bilateral lung infiltrates, which suggests aspiration pneumonia.

Mr. O is diagnosed with diabetes, complicated by DKA, and is treated in the intensive care unit (ICU). Despite resolution of the DKA, he remains altered with fever and tachycardia.

Continue to: On Day 6 of hospitalization...

On Day 6 of hospitalization, Mr. O continues to be tachycardic and obtunded with nuchal rigidity. The team decides to transfer Mr. O to another hospital for a higher level of care and continued workup of his persistent AMS.

Immediately upon arrival at the second hospital, infectious disease and neurology teams are consulted for further evaluation. Mr. O’s AMS continues despite no clear signs of infection or other neurologic insults.

[polldaddy:10930631]

The authors’ observations

Based on Mr. O’s psychiatric history and laboratory results, the first medical team concluded his initial AMS was likely secondary to DKA; however, the AMS continued after the DKA resolved. At the second hospital, Mr. O’s treatment team continued to dig for answers.

EVALUATION Exploring the differential diagnosis

At the second hospital, Mr. O is admitted to the ICU with fever (37.8°C), tachycardia (120 bpm), tachypnea, withdrawal from painful stimuli, decreased reflexes, and muscle rigidity, including clenched jaw. The differential diagnoses include meningitis, sepsis from aspiration pneumonia, severe metabolic encephalopathy with prolonged recovery, central pontine myelinolysis, anoxic brain injury, and subclinical seizures.

Empiric vancomycin, 1.75 g every 12 hours; ceftriaxone, 2 g/d; and acyclovir, 900 mg every 8 hours are started for meningoencephalitis, and all psychotropic medications are discontinued. Case reports have documented a relationship between hyperglycemic hyperosmolar syndrome (HHS) and malignant hyperthermia in rare cases¹; however, HHS is ruled out based on Mr. O’s laboratory results.A lumbar puncture and imaging rules out CNS infection. Antibiotic treatment is narrowed to ampicillin-sulbactam due to Mr. O’s prior CT chest showing concern for aspiration pneumonia. An MRI of the brain rules out central pontine myelinolysis, acute stroke, and anoxic brain injury, and an EEG shows nonspecific encephalopathy. On Day 10 of hospitalization, a neurologic exam shows flaccid paralysis and bilateral clonus, and Mr. O is mute. On Day 14 of hospitalization, his fever resolves, and his blood cultures are negative. On Day 15 of hospitalization, Mr. O’s creatine kinase (CK) level is elevated at 1,308 U/L (reference range 26 to 192 U/L), suggesting rhabdomyolysis.

Continue to: Given the neurologic exam findings...

Given the neurologic exam findings, and the limited evidence of infection, the differential diagnosis for Mr. O’s AMS is broadened to include catatonia, neuroleptic malignant syndrome (NMS), serotonin syndrome, and autoimmune encephalitis. The psychiatry team evaluates Mr. O for catatonia. He scores 14 on the Bush-Francis Catatonia Rating Scale, with findings of immobility/stupor, mutism, staring, autonomic instability, and withdrawal indicating the presence of catatonia.²

The authors’ observations

When Mr. O was transferred to the second hospital, the primary concern was to rule out meningitis due to his unstable vitals, obtunded mental state, and nuchal rigidity. A comprehensive infectious workup, including lumbar puncture, was imperative because infection can not only lead to AMS, but also precipitate episodes of DKA. Mr. O’s persistently abnormal vital signs indicated an underlying process may have been missed by focusing on treating DKA.

TREATMENT Finally, the diagnosis is established

A lorazepam challenge is performed, and Mr. O receives 4 mg of lorazepam over 24 hours with little change in his catatonia symptoms. Given his persistent fever, tachycardia, and an elevated CK levels in the context of recent exposure to antipsychotic medications, Mr. O is diagnosed with NMS (Table 1^3,4 ) and is started on bromocriptine, 5 mg 3 times daily.

[polldaddy:10930632]

The authors’ observations

Mr. O’s complicated medical state—starting with DKA, halting the use of antipsychotic medications, and the suspicion of catatonia due to his history of schizophrenia—all distracted from the ultimate diagnosis of NMS as the cause of his enduring AMS and autonomic instability. Catatonia and NMS have overlapping symptomatology, including rigidity, autonomic instability, and stupor, which make the diagnosis of either condition complicated. A positive lorazepam test to diagnose catatonia is defined as a marked reduction in catatonia symptoms (typically a 50% reduction) as measured on a standardized rating scale.⁵ However, a negative lorazepam challenge does not definitely rule out catatonia because some cases are resistant to benzodiazepines.⁶

NMS risk factors relevant in this case include male sex, young age, acute medical illness, dehydration, and exposure to multiple psychotropic medications, including 2 antipsychotics, clozapine and fluphenazine.⁷ DKA is especially pertinent due to its acute onset and cause of significant dehydration. NMS can occur at any point of antipsychotic exposure, although the risk is highest during the initial weeks of treatment and during dosage changes. Unfortunately, Mr. O’s treatment team was unable to determine whether his medication had been recently changed, so it is not known what role this may have played in the development of NMS. Although first-generation antipsychotics are considered more likely to cause NMS, second-generation antipsychotics (SGAs) dominate the treatment of schizophrenia and bipolar disorder, and these medications also can cause NMS.⁸ As occurred in this case, long-acting injectable antipsychotics can be easily forgotten when not administered in the hospital, and their presence in the body persists for weeks. For example, the half-life of fluphenazine decanoate is approximately 10 days, and the half-life of haloperidol decanoate is 21 days.⁹

Continue to: OUTCOME Improvement with bromocriptine

After 4 days of bromocriptine, 5 mg 3 times daily, Mr. O is more alert, able to say “hello,” and can follow 1-step commands. By Day 26 of hospitalization, his CK levels decrease to 296 U/L, his CSF autoimmune panel is negative, and he is able to participate in physical therapy. After failing multiple swallow tests, Mr. O requires a percutaneous endoscopic gastrostomy (PEG) tube. He is discharged from the hospital to a long-term acute care facility with the plan to taper bromocriptine and restart a psychotropic regimen with his outpatient psychiatrist. At the time of discharge, he is able to sit at the edge of the bed independently, state his name, and respond to questions with multiple-word answers.

[polldaddy:10930633]

The authors’ observations

The most common pharmacologic treatments for NMS are dantrolene, bromocriptine, benzodiazepines (lorazepam or diazepam), and amantadine.³ Mild cases of NMS should be treated with discontinuation of all antipsychotics, supportive care, and benzodiazepines.³ Bromocriptine or amantadine are more appropriate for moderate cases and dantrolene for severe cases of NMS.³ All antipsychotics should be discontinued while a patient is experiencing an episode of NMS; however, once the NMS has resolved, clinicians must thoroughly evaluate the risks and benefits of restarting antipsychotic medication. After a patient has experienced an episode of NMS, clinicians generally should avoid prescribing the agent(s) that caused NMS and long-acting injections, and slowly titrate a low-potency SGA such as quetiapine.¹⁰Table 2^3,11,12 outlines the pharmacologic treatment of NMS.

Bottom Line

Neuroleptic malignant syndrome (NMS) should always be part of the differential diagnosis in patients with mental illness and altered mental status. The risk of NMS is especially high in patients with acute medical illness and exposure to antipsychotic medications.

Related Resource

• Turner AH, Kim JJ, McCarron RM. Differentiating serotonin syndrome and neuroleptic malignant syndrome. Current Psychiatry. 2019;18(2):30-36.

Drug Brand Names

Acyclovir • Zovirax
Amantadine • Gocovri
Ampicillin-sulbactam • Unasyn
Aripiprazole • Abilify Maintena
Benztropine • Cogentin
Bromocriptine • Cycloset, Parlodel
Ceftriaxone • Rocephin
Clozapine • Clozaril
Dantrolene • Dantrium
Diazepam • Valium
Haloperidol • Haldol
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Paliperidone palmitate • Invega Sustenna
Quetiapine • Seroquel
Risperidone • Risperdal
Valproate sodium • Depakote
Trazodone • Oleptro
Vancomycin • Vancocin

CASE Sluggish, weak, and incoherent

Mr. O, age 24, who has a history of schizophrenia and obesity, presents to the emergency department (ED) for altered mental status (AMS). His mother reports that he has been sluggish, weak, incoherent, had no appetite, and that on the day before admission, he was drinking excessive amounts of water and urinating every 10 minutes.

HISTORY Multiple ineffective antipsychotics

Mr. O was diagnosed with schizophrenia at age 21 and struggled with medication adherence, which resulted in multiple hospitalizations for stabilization. Trials of haloperidol, risperidone, paliperidone palmitate, and valproic acid had been ineffective. At the time of admission, his psychotropic medication regimen is fluphenazine decanoate, 25 mg injection every 2 weeks; clozapine, 50 mg/d; lithium carbonate, 300 mg twice a day; benztropine, 2 mg every night; and trazodone, 50 mg every night.

EVALUATION Fever, tachycardia, and diabetic ketoacidosis

Upon arrival to the ED, Mr. O is obtunded, unable to follow commands, and does not respond to painful stimuli. On physical exam, he has a fever of 38.4°C (reference range 35.1°C to 37.9°C); tachycardia with a heart rate of 142 beats per minute (bpm) (reference range 60 to 100); tachypnea with a respiratory rate of 35 breaths per minute (reference range 12 to 20); a blood pressure of 116/76 mmHg (reference range 90/60 to 130/80); and hypoxemia with an oxygen saturation of 90% on room air (reference range 94% to 100%).

Mr. O is admitted to the hospital and his laboratory workup indicates diabetic ketoacidosis (DKA), with a glucose of 1,700 mg/dL; anion gap of 30 (reference range 4 to 12 mmol/L); pH 7.04 (reference range 7.32 to 7.42); serum bicarbonate 6 (reference range 20 to 24 mEq/L); beta-hydroxybutyrate 11.04 (reference range 0 to 0.27 mmol/L); urine ketones, serum osmolality 407 (reference range 280 to 300 mOsm/kg); and an elevated white blood cell count of 18.4 (reference range 4.5 to 11.0 × 10⁹/L). A CT scan of the head is negative for acute pathology.

Initially, all psychotropic medications are held. On Day 3 of hospitalization, psychiatry is consulted and clozapine, 50 mg/d; lithium, 300 mg/d; and benztropine, 1 mg at night, are restarted; however, fluphenazine decanoate and trazodone are held. The team recommends IV haloperidol, 2 mg as needed for agitation; however, it is never administered.

Imaging rules out deep vein thrombosis, cardiac dysfunction, and stroke, but a CT chest scan is notable for bilateral lung infiltrates, which suggests aspiration pneumonia.

Mr. O is diagnosed with diabetes, complicated by DKA, and is treated in the intensive care unit (ICU). Despite resolution of the DKA, he remains altered with fever and tachycardia.

Continue to: On Day 6 of hospitalization...

On Day 6 of hospitalization, Mr. O continues to be tachycardic and obtunded with nuchal rigidity. The team decides to transfer Mr. O to another hospital for a higher level of care and continued workup of his persistent AMS.

Immediately upon arrival at the second hospital, infectious disease and neurology teams are consulted for further evaluation. Mr. O’s AMS continues despite no clear signs of infection or other neurologic insults.

[polldaddy:10930631]

The authors’ observations

Based on Mr. O’s psychiatric history and laboratory results, the first medical team concluded his initial AMS was likely secondary to DKA; however, the AMS continued after the DKA resolved. At the second hospital, Mr. O’s treatment team continued to dig for answers.

EVALUATION Exploring the differential diagnosis

At the second hospital, Mr. O is admitted to the ICU with fever (37.8°C), tachycardia (120 bpm), tachypnea, withdrawal from painful stimuli, decreased reflexes, and muscle rigidity, including clenched jaw. The differential diagnoses include meningitis, sepsis from aspiration pneumonia, severe metabolic encephalopathy with prolonged recovery, central pontine myelinolysis, anoxic brain injury, and subclinical seizures.

Empiric vancomycin, 1.75 g every 12 hours; ceftriaxone, 2 g/d; and acyclovir, 900 mg every 8 hours are started for meningoencephalitis, and all psychotropic medications are discontinued. Case reports have documented a relationship between hyperglycemic hyperosmolar syndrome (HHS) and malignant hyperthermia in rare cases¹; however, HHS is ruled out based on Mr. O’s laboratory results.A lumbar puncture and imaging rules out CNS infection. Antibiotic treatment is narrowed to ampicillin-sulbactam due to Mr. O’s prior CT chest showing concern for aspiration pneumonia. An MRI of the brain rules out central pontine myelinolysis, acute stroke, and anoxic brain injury, and an EEG shows nonspecific encephalopathy. On Day 10 of hospitalization, a neurologic exam shows flaccid paralysis and bilateral clonus, and Mr. O is mute. On Day 14 of hospitalization, his fever resolves, and his blood cultures are negative. On Day 15 of hospitalization, Mr. O’s creatine kinase (CK) level is elevated at 1,308 U/L (reference range 26 to 192 U/L), suggesting rhabdomyolysis.

Continue to: Given the neurologic exam findings...

Given the neurologic exam findings, and the limited evidence of infection, the differential diagnosis for Mr. O’s AMS is broadened to include catatonia, neuroleptic malignant syndrome (NMS), serotonin syndrome, and autoimmune encephalitis. The psychiatry team evaluates Mr. O for catatonia. He scores 14 on the Bush-Francis Catatonia Rating Scale, with findings of immobility/stupor, mutism, staring, autonomic instability, and withdrawal indicating the presence of catatonia.²

The authors’ observations

When Mr. O was transferred to the second hospital, the primary concern was to rule out meningitis due to his unstable vitals, obtunded mental state, and nuchal rigidity. A comprehensive infectious workup, including lumbar puncture, was imperative because infection can not only lead to AMS, but also precipitate episodes of DKA. Mr. O’s persistently abnormal vital signs indicated an underlying process may have been missed by focusing on treating DKA.

TREATMENT Finally, the diagnosis is established

A lorazepam challenge is performed, and Mr. O receives 4 mg of lorazepam over 24 hours with little change in his catatonia symptoms. Given his persistent fever, tachycardia, and an elevated CK levels in the context of recent exposure to antipsychotic medications, Mr. O is diagnosed with NMS (Table 1^3,4 ) and is started on bromocriptine, 5 mg 3 times daily.

[polldaddy:10930632]

The authors’ observations

Mr. O’s complicated medical state—starting with DKA, halting the use of antipsychotic medications, and the suspicion of catatonia due to his history of schizophrenia—all distracted from the ultimate diagnosis of NMS as the cause of his enduring AMS and autonomic instability. Catatonia and NMS have overlapping symptomatology, including rigidity, autonomic instability, and stupor, which make the diagnosis of either condition complicated. A positive lorazepam test to diagnose catatonia is defined as a marked reduction in catatonia symptoms (typically a 50% reduction) as measured on a standardized rating scale.⁵ However, a negative lorazepam challenge does not definitely rule out catatonia because some cases are resistant to benzodiazepines.⁶

NMS risk factors relevant in this case include male sex, young age, acute medical illness, dehydration, and exposure to multiple psychotropic medications, including 2 antipsychotics, clozapine and fluphenazine.⁷ DKA is especially pertinent due to its acute onset and cause of significant dehydration. NMS can occur at any point of antipsychotic exposure, although the risk is highest during the initial weeks of treatment and during dosage changes. Unfortunately, Mr. O’s treatment team was unable to determine whether his medication had been recently changed, so it is not known what role this may have played in the development of NMS. Although first-generation antipsychotics are considered more likely to cause NMS, second-generation antipsychotics (SGAs) dominate the treatment of schizophrenia and bipolar disorder, and these medications also can cause NMS.⁸ As occurred in this case, long-acting injectable antipsychotics can be easily forgotten when not administered in the hospital, and their presence in the body persists for weeks. For example, the half-life of fluphenazine decanoate is approximately 10 days, and the half-life of haloperidol decanoate is 21 days.⁹

Continue to: OUTCOME Improvement with bromocriptine

After 4 days of bromocriptine, 5 mg 3 times daily, Mr. O is more alert, able to say “hello,” and can follow 1-step commands. By Day 26 of hospitalization, his CK levels decrease to 296 U/L, his CSF autoimmune panel is negative, and he is able to participate in physical therapy. After failing multiple swallow tests, Mr. O requires a percutaneous endoscopic gastrostomy (PEG) tube. He is discharged from the hospital to a long-term acute care facility with the plan to taper bromocriptine and restart a psychotropic regimen with his outpatient psychiatrist. At the time of discharge, he is able to sit at the edge of the bed independently, state his name, and respond to questions with multiple-word answers.

[polldaddy:10930633]

The authors’ observations

The most common pharmacologic treatments for NMS are dantrolene, bromocriptine, benzodiazepines (lorazepam or diazepam), and amantadine.³ Mild cases of NMS should be treated with discontinuation of all antipsychotics, supportive care, and benzodiazepines.³ Bromocriptine or amantadine are more appropriate for moderate cases and dantrolene for severe cases of NMS.³ All antipsychotics should be discontinued while a patient is experiencing an episode of NMS; however, once the NMS has resolved, clinicians must thoroughly evaluate the risks and benefits of restarting antipsychotic medication. After a patient has experienced an episode of NMS, clinicians generally should avoid prescribing the agent(s) that caused NMS and long-acting injections, and slowly titrate a low-potency SGA such as quetiapine.¹⁰Table 2^3,11,12 outlines the pharmacologic treatment of NMS.

Bottom Line

Neuroleptic malignant syndrome (NMS) should always be part of the differential diagnosis in patients with mental illness and altered mental status. The risk of NMS is especially high in patients with acute medical illness and exposure to antipsychotic medications.

Related Resource

• Turner AH, Kim JJ, McCarron RM. Differentiating serotonin syndrome and neuroleptic malignant syndrome. Current Psychiatry. 2019;18(2):30-36.

Drug Brand Names

Acyclovir • Zovirax
Amantadine • Gocovri
Ampicillin-sulbactam • Unasyn
Aripiprazole • Abilify Maintena
Benztropine • Cogentin
Bromocriptine • Cycloset, Parlodel
Ceftriaxone • Rocephin
Clozapine • Clozaril
Dantrolene • Dantrium
Diazepam • Valium
Haloperidol • Haldol
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Paliperidone palmitate • Invega Sustenna
Quetiapine • Seroquel
Risperidone • Risperdal
Valproate sodium • Depakote
Trazodone • Oleptro
Vancomycin • Vancocin

Mentoring is often promoted as an organizational practice to promote diversity and inclusion. New or established group members who want to further their careers look for a mentor to guide them toward success within a system by amplifying their strengths and accomplishments and defending and promoting them when necessary. But how can mentoring work if there isn’t a mentor?

For underrepresented groups or marginalized physicians, it too often looks as if there are no mentors who understand the struggles of being a racial or ethnic minority group member or mentors who are even cognizant of those struggles. Mentoring is a practice that occurs within the overarching systems of practice groups, academic departments, hospitals, medicine, and society at large. These systems frequently carry the legacies of bias, discrimination, and exclusion. The mentoring itself that takes place within a biased system risks perpetuating institutional bias, exclusion, or a sense of unworthiness in the mentee. It is stressful for any person with a minority background or even a minority interest to feel that there’s no one to emulate in their immediate working environment. When that is the case, a natural question follows: “Do I even belong here?”

Before departments and psychiatric practices turn to old, surface-level solutions like using mentorship to appear more welcoming to underrepresented groups, leaders must explicitly evaluate their track record of mentorship within their system and determine whether mentorship has been used to protect the status quo or move the culture forward. As mentorship is inherently an imbalanced relationship, there must be department- or group-level reflection about the diversity of mentors and also their examinations of mentors’ own preconceived notions of who will make a “good” mentee.

At the most basic level, leaders can examine whether there are gaps in who is mentored and who is not. Other parts of mentoring relationships should also be examined: a) How can mentoring happen if there is a dearth of underrepresented groups in the department? b) What type of mentoring style is favored? Do departments/groups look for a natural fit between mentor and mentee or are they matched based on interests, ideals, and goals? and c) How is the worthiness for mentorship determined?

One example is the fraught process of evaluating “worthiness” among residents. Prospective mentors frequently divide trainees unofficially into a top-tier candidates, middle-tier performers who may be overlooked, and a bottom tier who are avoided when it comes to mentorship. Because this division is informal and usually based on extremely early perceptions of trainees’ aptitude and openness, the process can be subject to an individual mentor’s conscious and unconscious bias, which then plays a large role in perpetuating systemic racism. When it comes to these informal but often rigid divisions, it can be hard to fall from the top when mentees are buoyed by good will, frequent opportunities to shine, and the mentor’s reputation. Likewise, it can be hard to break out from the middle and bottom groups without a strong advocate or opportunities to demonstrate exceptional proficiency.

Below are three recommendations to consider for improving mentorship within departments:

1) Consider opportunities for senior mentors and potential mentees to interact with one another outside of assigned duties so that some mentorship relationships can be formed organically.

2) Review when mentorship relationships have been ineffective or unsuccessful versus productive and useful for both participants.

3) Increase opportunities for adjunct or former faculty who remain connected to the institution to also be mentors. This approach would open up more possibilities and could increase the diversity of available mentors.

If mentorship is to be part of the armamentarium for promoting equity within academia and workplaces alike, it must be examined and changed to meet the new reality.

Dr. Posada is assistant clinical professor, department of psychiatry and behavioral sciences at George Washington University in Washington. She also serves as staff physician at George Washington Medical Faculty Associates, also in Washington. She disclosed no relevant financial relationships. Dr. Forrester is consultation-liaison psychiatry fellowship training director at the University of Maryland, Baltimore. She disclosed no relevant financial relationships.

Mentoring is often promoted as an organizational practice to promote diversity and inclusion. New or established group members who want to further their careers look for a mentor to guide them toward success within a system by amplifying their strengths and accomplishments and defending and promoting them when necessary. But how can mentoring work if there isn’t a mentor?

For underrepresented groups or marginalized physicians, it too often looks as if there are no mentors who understand the struggles of being a racial or ethnic minority group member or mentors who are even cognizant of those struggles. Mentoring is a practice that occurs within the overarching systems of practice groups, academic departments, hospitals, medicine, and society at large. These systems frequently carry the legacies of bias, discrimination, and exclusion. The mentoring itself that takes place within a biased system risks perpetuating institutional bias, exclusion, or a sense of unworthiness in the mentee. It is stressful for any person with a minority background or even a minority interest to feel that there’s no one to emulate in their immediate working environment. When that is the case, a natural question follows: “Do I even belong here?”

Before departments and psychiatric practices turn to old, surface-level solutions like using mentorship to appear more welcoming to underrepresented groups, leaders must explicitly evaluate their track record of mentorship within their system and determine whether mentorship has been used to protect the status quo or move the culture forward. As mentorship is inherently an imbalanced relationship, there must be department- or group-level reflection about the diversity of mentors and also their examinations of mentors’ own preconceived notions of who will make a “good” mentee.

At the most basic level, leaders can examine whether there are gaps in who is mentored and who is not. Other parts of mentoring relationships should also be examined: a) How can mentoring happen if there is a dearth of underrepresented groups in the department? b) What type of mentoring style is favored? Do departments/groups look for a natural fit between mentor and mentee or are they matched based on interests, ideals, and goals? and c) How is the worthiness for mentorship determined?

One example is the fraught process of evaluating “worthiness” among residents. Prospective mentors frequently divide trainees unofficially into a top-tier candidates, middle-tier performers who may be overlooked, and a bottom tier who are avoided when it comes to mentorship. Because this division is informal and usually based on extremely early perceptions of trainees’ aptitude and openness, the process can be subject to an individual mentor’s conscious and unconscious bias, which then plays a large role in perpetuating systemic racism. When it comes to these informal but often rigid divisions, it can be hard to fall from the top when mentees are buoyed by good will, frequent opportunities to shine, and the mentor’s reputation. Likewise, it can be hard to break out from the middle and bottom groups without a strong advocate or opportunities to demonstrate exceptional proficiency.

Below are three recommendations to consider for improving mentorship within departments:

1) Consider opportunities for senior mentors and potential mentees to interact with one another outside of assigned duties so that some mentorship relationships can be formed organically.

2) Review when mentorship relationships have been ineffective or unsuccessful versus productive and useful for both participants.

3) Increase opportunities for adjunct or former faculty who remain connected to the institution to also be mentors. This approach would open up more possibilities and could increase the diversity of available mentors.

If mentorship is to be part of the armamentarium for promoting equity within academia and workplaces alike, it must be examined and changed to meet the new reality.

Dr. Posada is assistant clinical professor, department of psychiatry and behavioral sciences at George Washington University in Washington. She also serves as staff physician at George Washington Medical Faculty Associates, also in Washington. She disclosed no relevant financial relationships. Dr. Forrester is consultation-liaison psychiatry fellowship training director at the University of Maryland, Baltimore. She disclosed no relevant financial relationships.

Mentoring is often promoted as an organizational practice to promote diversity and inclusion. New or established group members who want to further their careers look for a mentor to guide them toward success within a system by amplifying their strengths and accomplishments and defending and promoting them when necessary. But how can mentoring work if there isn’t a mentor?

For underrepresented groups or marginalized physicians, it too often looks as if there are no mentors who understand the struggles of being a racial or ethnic minority group member or mentors who are even cognizant of those struggles. Mentoring is a practice that occurs within the overarching systems of practice groups, academic departments, hospitals, medicine, and society at large. These systems frequently carry the legacies of bias, discrimination, and exclusion. The mentoring itself that takes place within a biased system risks perpetuating institutional bias, exclusion, or a sense of unworthiness in the mentee. It is stressful for any person with a minority background or even a minority interest to feel that there’s no one to emulate in their immediate working environment. When that is the case, a natural question follows: “Do I even belong here?”

Before departments and psychiatric practices turn to old, surface-level solutions like using mentorship to appear more welcoming to underrepresented groups, leaders must explicitly evaluate their track record of mentorship within their system and determine whether mentorship has been used to protect the status quo or move the culture forward. As mentorship is inherently an imbalanced relationship, there must be department- or group-level reflection about the diversity of mentors and also their examinations of mentors’ own preconceived notions of who will make a “good” mentee.

At the most basic level, leaders can examine whether there are gaps in who is mentored and who is not. Other parts of mentoring relationships should also be examined: a) How can mentoring happen if there is a dearth of underrepresented groups in the department? b) What type of mentoring style is favored? Do departments/groups look for a natural fit between mentor and mentee or are they matched based on interests, ideals, and goals? and c) How is the worthiness for mentorship determined?

One example is the fraught process of evaluating “worthiness” among residents. Prospective mentors frequently divide trainees unofficially into a top-tier candidates, middle-tier performers who may be overlooked, and a bottom tier who are avoided when it comes to mentorship. Because this division is informal and usually based on extremely early perceptions of trainees’ aptitude and openness, the process can be subject to an individual mentor’s conscious and unconscious bias, which then plays a large role in perpetuating systemic racism. When it comes to these informal but often rigid divisions, it can be hard to fall from the top when mentees are buoyed by good will, frequent opportunities to shine, and the mentor’s reputation. Likewise, it can be hard to break out from the middle and bottom groups without a strong advocate or opportunities to demonstrate exceptional proficiency.

Below are three recommendations to consider for improving mentorship within departments:

1) Consider opportunities for senior mentors and potential mentees to interact with one another outside of assigned duties so that some mentorship relationships can be formed organically.

2) Review when mentorship relationships have been ineffective or unsuccessful versus productive and useful for both participants.

3) Increase opportunities for adjunct or former faculty who remain connected to the institution to also be mentors. This approach would open up more possibilities and could increase the diversity of available mentors.

If mentorship is to be part of the armamentarium for promoting equity within academia and workplaces alike, it must be examined and changed to meet the new reality.

Dr. Posada is assistant clinical professor, department of psychiatry and behavioral sciences at George Washington University in Washington. She also serves as staff physician at George Washington Medical Faculty Associates, also in Washington. She disclosed no relevant financial relationships. Dr. Forrester is consultation-liaison psychiatry fellowship training director at the University of Maryland, Baltimore. She disclosed no relevant financial relationships.

A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.

As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.

All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.

Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.

I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.

A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.

The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.

The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:

• Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
• Reach out to loved ones and friends who remind you of strength and better times.
• Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
• Take care of your body and mind with exercise.
• Try for 8 hours of sleep a night (even if it doesn’t happen).
• Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.

During this crisis, tactful self-disclosure might be appropriate and therapeutic. All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.

Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.

After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.

Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.

As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.

Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.

I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.

Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.

A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.

As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.

All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.

Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.

I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.

A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.

The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.

The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:

• Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
• Reach out to loved ones and friends who remind you of strength and better times.
• Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
• Take care of your body and mind with exercise.
• Try for 8 hours of sleep a night (even if it doesn’t happen).
• Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.

During this crisis, tactful self-disclosure might be appropriate and therapeutic. All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.

Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.

After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.

Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.

As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.

Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.

I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.

Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.

A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.

As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.

All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.

Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.

I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.

A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.

The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.

The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:

• Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
• Reach out to loved ones and friends who remind you of strength and better times.
• Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
• Take care of your body and mind with exercise.
• Try for 8 hours of sleep a night (even if it doesn’t happen).
• Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.

During this crisis, tactful self-disclosure might be appropriate and therapeutic. All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.

Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.

After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.

Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.

As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.

Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.

I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.

Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.

As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.

The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.

On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.

The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.

On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. A public health emergency like COVID-19 is a time for flexibility and thoughtful planning. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.

As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.

If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.

For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.

For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.

Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.

As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.

If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. It’s a time for flexibility but also to flex our muscles as health care professionals. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
 

Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.

As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.

The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.

On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.

The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.

On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. A public health emergency like COVID-19 is a time for flexibility and thoughtful planning. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.

As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.

If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.

For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.

For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.

Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.

As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.

If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. It’s a time for flexibility but also to flex our muscles as health care professionals. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
 

Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.

As the COVID-19 pandemic spreads, it now seems like the norm is that large medical conferences are being canceled.

The American Psychiatric Association (APA) canceled its 2020 annual meeting, which was scheduled for late April. The cancellation disappointed many, because we will miss out on the camaraderie and professional invigoration that comes from gathering with psychiatrists and other mental health professionals from across the United States and around the world. After the APA’s decision was announced, the White House released guidelines advising Americans to avoid social gatherings of 10 or more people.

On a practical level, many psychiatrists will not be able to earn up to 35 continuing medical education credits (CME) from attending the meeting and fulfilling the administrative requirements to obtain a CME certificate. Not only have meetings been canceled, but events many other clinicians count on for CME, such as journal clubs and department grand rounds, have been canceled until they can be moved to a virtual space.

The CME requirements for state medical licenses vary widely. On average, most states require at least 25 credits per year or 60 to 100 credits every 2 years, and the American Board of Psychiatry and Neurology requires diplomates to complete an average of 30 specialty and/or subspecialty CME credits per year, averaged over 3 years. Usually, annual medical conferences would be a great way to get an infusion of CME credits, brush up on cutting-edge treatments, and review the basics.

On top of everything else we have to worry about with COVID-19, getting enough CME credits has been added to the list for many psychiatrists and mental health clinicians. A public health emergency like COVID-19 is a time for flexibility and thoughtful planning. As our schedules and daily lives are disrupted, it’s important to find relief in routine activities that are not affected by social distancing and fears of isolation and quarantine. A routine activity to lean into might include learning or practicing a skill that we enjoy, such as psychiatry (hopefully!) and the practice of medicine. The CME could be focused on a psychiatric topic or perhaps learning about the specifics of COVID-19 or brushing up on medical knowledge that might be a bit rusty after many years of practicing solely psychiatry.

As you start to gather CME credits online, it’s helpful to sign up for a service that stores your CME credits and helps you keep track of the number. When it comes time to renew your medical license or apply for maintenance of certification (MOC), who wants to be the person searching through their email for PDFs of CME certificates or taking pictures or scanning paper certificates? The APA has a section under education and MOC to track certificates earned by watching online modules from its “Learning Center.” The website also allows users to upload external certificates. The American Medical Association offers a similar service on its “Ed Hub,” in which users can log in to watch, listen, or download articles to earn CME credits after finishing the associated quiz. Medscape, in the CME and Education section, also offers an easy-to-use CME dashboard, in which clinicians can filter by their specialty, topic, duration of learning activity – ranging from 0.25 to 3 CME credits. Clinicians also can track their credits as they complete activities.

If you’re someone who’s having trouble focusing on anything besides COVID-19, there are COVID-19-specific CME activities that are available and can help psychiatrists feel comfortable talking with patients, family, and their institutions about the risks of COVID-19. The AMA Ed Hub has a featured 8-credit CME course about the novel coronavirus with updates about diagnosis, treatment, and public health strategies.

For the psychiatrists who may have procrastinated in-depth learning about the opioid crisis or getting their buprenorphine waivers, AMA Ed Hub offers a 42-credit course about opioids and pain management covering guidelines, research, and treatment.

For fun refreshers on general medicine, the New England Journal of Medicine offers up to 20 online CME exams based on quizzes from interesting clinical cases ranging from “regular” medicine to rare clinical scenarios. The APA Learning Center has an easy-to-use search function allowing users to select content from more than 200 modules covering a wide range of general topics; from reviewing recent treatment guidelines to specialized psychiatric topics such as geriatric bipolar disorder. A psychiatrist who has been quickly pushed to telepsychiatry because of the current pandemic could use the APA Learning Center to find educational modules about risk management in telepsychiatry or learn the special considerations of using telepsychiatry to treat patients with serious mental illness.

Using podcasts to earn CME is becoming increasingly common, with such as outlets as JAMA Networks offering podcasts in many specialties in which subscribers can take a quiz through the JAMA app and obtain CME credits.

As our clinical boundaries as psychiatrists are pushed by an ever-changing public health situation, now is the time to earn CME focused on new topics to meet the demands placed on health care workers at the front lines of clinical care.

If the COVID-19 pandemic reaches the number of cases predicted by public health officials, our health care system is going to be under extreme stress. All specialties face the threat of losing part of their working capacity as clinicians get sick with the virus, or as they stay home because of exposure or to take care of a loved one. It’s a time for flexibility but also to flex our muscles as health care professionals. CME can be a way to empower ourselves by staying current on the cutting edge of our specialties, but also brushing up on the medicine that we may be asked to practice in a time of great need.
 

Dr. Posada is consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. She also is associate producer of the MDedge Psychcast. Dr. Posada has no disclosures.

A transition is coming. My fourth and final year of residency starts soon – meaning that from July 1, 2018, I’ll never again be on call overnight as a psychiatry resident. July 1 marks the end of 2 years as a PGY2 and PGY3, during which I’ve worked 60 overnight shifts.

In our residency program, the on-call shift is a continuation of daytime duties, and the experience is a formative physician-in-training/quasi-hazing process of care provision for 24 hours straight. Previously, I’ve recounted experiences from my overnight on-call shifts and reflected on the intensity of working with emotionally distressed individuals in the emergency department. I never thought I’d say it, but I will miss working in the middle of the night, particularly in the ED. In the small hours of the morning, the strange aura of hospital existence, and desperation of sickness isn’t washed out by daylight and the inhibitions of business hours.

Thomas Northcut/Thinkstock

• 0: There is no such thing as 0 emotional pain when asked to stay overnight in the hospital.

• 1: This is a full night of sleep on the uncomfortable bunk beds in the GWU call room. On occasion, I’ve had a night with one consult. Only once in 2 years did I have a night in which not a single consult was called from the ED and all the patients on the psychiatric unit slept as soundly as I did.
• 4: There’s a man I’ve seen in the ED seven times over the last 2 years. That’s more than 10% of my nights on call, so we’re well acquainted – though he has trouble remembering me. He’s an alcoholic, though I know the official diagnosis is alcohol use disorder–severe. His addiction is, indeed, severe; I’ve never seen him sober. Every time, he tells me how his wife is cheating on him, and he’s been depressed since his eldest son was killed in a shooting 10 years ago. He sits under a bridge and drinks liquor until he either goes home or to an ED. I feel for him. Several times, other residents and I have transferred him to a local detoxification unit with discharge to a 30-day drug rehab program. It doesn’t stick. The last time I evaluated him, I sent him home to his wife with a cab voucher. My emotional pain is equal parts pity and frustration over my ineffectual impact on his life. He, and others like him, used to cause me more emotional pain. Eventually, the pain is dulled.

  

• 5: The mean pain scale score of a GWU resident on call is 5.13. Analysis of the survey data showed the emotional pain score is correlated with the specific resident on call, and my personal average is 5.04. From the way residents talk about being on call, I expected the mean pain scale to be higher. There is no vignette for the mean score; I think of it as all the unremarkable calls blurred together.
• 8: Emotional pain rises with a fraught clinical scenario. One weeknight, I had to involuntarily commit a young lawyer who was psychotic yet adept at hiding it. The lawyer was brought into the ED by police after his brother in Chicago called them to his apartment. The patient had called the brother while standing on his 10th-floor balcony talking nonsensically about conspiracy theories and why he needed to end his life to save the world. In the ED, the patient denied every single part of the story. When I called the brother for collateral, his distress moved me as a both sibling and psychiatrist. The lawyer denied the story up and down, called his brother a liar and the favorite child, and refused to sign into the psychiatric hospital voluntarily. I felt I had no choice but to place him in an involuntary hold. It was a long and busy night, and every time I walked past his ED bay, he’d yell, “Is this the face of a crazy man? I know the law!” I tried to put myself in his position and that of his brother who had called the police. Eight is the emotional pain of involuntarily committing someone whose story isn’t black and white. Eight is the pain of exercising authority and beneficence over patient autonomy.

• 10: I was consulted to evaluate a woman for suicidal ideation whose mother had coded and died in the ED an hour before. When the woman was told of her mother’s death, she crumpled to floor, screaming she wanted to die to join her mother. In the tumult, ED staff thought she was running out of the hospital to jump into traffic. She was held in the ED involuntarily until she could be evaluated for safety by psychiatry – me. When I entered her hospital room, she was quietly weeping, whispering: “I want my mom. I want my mom.” I wanted to cry, too. I sat with her in silence for a few minutes and offered my condolences. Yet, as the consultant, I had a job to do: I needed to complete a risk assessment. My voice caught as I explained that I was here to assess her for suicidal thoughts and plans. She looked at me like I was crazy. I felt crazy. I acknowledged the risk of suicide and her expressed desire to join her mother in death. I asked the questions quickly and gently. She shook her head to all my questions and told me she just wanted to go home. I met her daughters in the waiting room who were caught up in grief over the combination of their grandmother’s death and their mother’s reaction. They seemed certain that their mother had not wanted to die, and we agreed it was a situation of the wrong reaction in the wrong place. The daughters agreed to take her home and watch her all night. This is the only 10 I’ve experienced on the emotional pain scale. I felt shame and confusion as I struggled to reconcile my obligation as a psychiatrist, and my true desire to give that woman a hug and send her home without a battery of questions at perhaps her most vulnerable moment.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at GWU. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

A transition is coming. My fourth and final year of residency starts soon – meaning that from July 1, 2018, I’ll never again be on call overnight as a psychiatry resident. July 1 marks the end of 2 years as a PGY2 and PGY3, during which I’ve worked 60 overnight shifts.

In our residency program, the on-call shift is a continuation of daytime duties, and the experience is a formative physician-in-training/quasi-hazing process of care provision for 24 hours straight. Previously, I’ve recounted experiences from my overnight on-call shifts and reflected on the intensity of working with emotionally distressed individuals in the emergency department. I never thought I’d say it, but I will miss working in the middle of the night, particularly in the ED. In the small hours of the morning, the strange aura of hospital existence, and desperation of sickness isn’t washed out by daylight and the inhibitions of business hours.

Thomas Northcut/Thinkstock

• 0: There is no such thing as 0 emotional pain when asked to stay overnight in the hospital.

• 1: This is a full night of sleep on the uncomfortable bunk beds in the GWU call room. On occasion, I’ve had a night with one consult. Only once in 2 years did I have a night in which not a single consult was called from the ED and all the patients on the psychiatric unit slept as soundly as I did.
• 4: There’s a man I’ve seen in the ED seven times over the last 2 years. That’s more than 10% of my nights on call, so we’re well acquainted – though he has trouble remembering me. He’s an alcoholic, though I know the official diagnosis is alcohol use disorder–severe. His addiction is, indeed, severe; I’ve never seen him sober. Every time, he tells me how his wife is cheating on him, and he’s been depressed since his eldest son was killed in a shooting 10 years ago. He sits under a bridge and drinks liquor until he either goes home or to an ED. I feel for him. Several times, other residents and I have transferred him to a local detoxification unit with discharge to a 30-day drug rehab program. It doesn’t stick. The last time I evaluated him, I sent him home to his wife with a cab voucher. My emotional pain is equal parts pity and frustration over my ineffectual impact on his life. He, and others like him, used to cause me more emotional pain. Eventually, the pain is dulled.

  

• 5: The mean pain scale score of a GWU resident on call is 5.13. Analysis of the survey data showed the emotional pain score is correlated with the specific resident on call, and my personal average is 5.04. From the way residents talk about being on call, I expected the mean pain scale to be higher. There is no vignette for the mean score; I think of it as all the unremarkable calls blurred together.
• 8: Emotional pain rises with a fraught clinical scenario. One weeknight, I had to involuntarily commit a young lawyer who was psychotic yet adept at hiding it. The lawyer was brought into the ED by police after his brother in Chicago called them to his apartment. The patient had called the brother while standing on his 10th-floor balcony talking nonsensically about conspiracy theories and why he needed to end his life to save the world. In the ED, the patient denied every single part of the story. When I called the brother for collateral, his distress moved me as a both sibling and psychiatrist. The lawyer denied the story up and down, called his brother a liar and the favorite child, and refused to sign into the psychiatric hospital voluntarily. I felt I had no choice but to place him in an involuntary hold. It was a long and busy night, and every time I walked past his ED bay, he’d yell, “Is this the face of a crazy man? I know the law!” I tried to put myself in his position and that of his brother who had called the police. Eight is the emotional pain of involuntarily committing someone whose story isn’t black and white. Eight is the pain of exercising authority and beneficence over patient autonomy.

• 10: I was consulted to evaluate a woman for suicidal ideation whose mother had coded and died in the ED an hour before. When the woman was told of her mother’s death, she crumpled to floor, screaming she wanted to die to join her mother. In the tumult, ED staff thought she was running out of the hospital to jump into traffic. She was held in the ED involuntarily until she could be evaluated for safety by psychiatry – me. When I entered her hospital room, she was quietly weeping, whispering: “I want my mom. I want my mom.” I wanted to cry, too. I sat with her in silence for a few minutes and offered my condolences. Yet, as the consultant, I had a job to do: I needed to complete a risk assessment. My voice caught as I explained that I was here to assess her for suicidal thoughts and plans. She looked at me like I was crazy. I felt crazy. I acknowledged the risk of suicide and her expressed desire to join her mother in death. I asked the questions quickly and gently. She shook her head to all my questions and told me she just wanted to go home. I met her daughters in the waiting room who were caught up in grief over the combination of their grandmother’s death and their mother’s reaction. They seemed certain that their mother had not wanted to die, and we agreed it was a situation of the wrong reaction in the wrong place. The daughters agreed to take her home and watch her all night. This is the only 10 I’ve experienced on the emotional pain scale. I felt shame and confusion as I struggled to reconcile my obligation as a psychiatrist, and my true desire to give that woman a hug and send her home without a battery of questions at perhaps her most vulnerable moment.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at GWU. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

A transition is coming. My fourth and final year of residency starts soon – meaning that from July 1, 2018, I’ll never again be on call overnight as a psychiatry resident. July 1 marks the end of 2 years as a PGY2 and PGY3, during which I’ve worked 60 overnight shifts.

In our residency program, the on-call shift is a continuation of daytime duties, and the experience is a formative physician-in-training/quasi-hazing process of care provision for 24 hours straight. Previously, I’ve recounted experiences from my overnight on-call shifts and reflected on the intensity of working with emotionally distressed individuals in the emergency department. I never thought I’d say it, but I will miss working in the middle of the night, particularly in the ED. In the small hours of the morning, the strange aura of hospital existence, and desperation of sickness isn’t washed out by daylight and the inhibitions of business hours.

Thomas Northcut/Thinkstock

• 0: There is no such thing as 0 emotional pain when asked to stay overnight in the hospital.

• 1: This is a full night of sleep on the uncomfortable bunk beds in the GWU call room. On occasion, I’ve had a night with one consult. Only once in 2 years did I have a night in which not a single consult was called from the ED and all the patients on the psychiatric unit slept as soundly as I did.
• 4: There’s a man I’ve seen in the ED seven times over the last 2 years. That’s more than 10% of my nights on call, so we’re well acquainted – though he has trouble remembering me. He’s an alcoholic, though I know the official diagnosis is alcohol use disorder–severe. His addiction is, indeed, severe; I’ve never seen him sober. Every time, he tells me how his wife is cheating on him, and he’s been depressed since his eldest son was killed in a shooting 10 years ago. He sits under a bridge and drinks liquor until he either goes home or to an ED. I feel for him. Several times, other residents and I have transferred him to a local detoxification unit with discharge to a 30-day drug rehab program. It doesn’t stick. The last time I evaluated him, I sent him home to his wife with a cab voucher. My emotional pain is equal parts pity and frustration over my ineffectual impact on his life. He, and others like him, used to cause me more emotional pain. Eventually, the pain is dulled.

  

• 5: The mean pain scale score of a GWU resident on call is 5.13. Analysis of the survey data showed the emotional pain score is correlated with the specific resident on call, and my personal average is 5.04. From the way residents talk about being on call, I expected the mean pain scale to be higher. There is no vignette for the mean score; I think of it as all the unremarkable calls blurred together.
• 8: Emotional pain rises with a fraught clinical scenario. One weeknight, I had to involuntarily commit a young lawyer who was psychotic yet adept at hiding it. The lawyer was brought into the ED by police after his brother in Chicago called them to his apartment. The patient had called the brother while standing on his 10th-floor balcony talking nonsensically about conspiracy theories and why he needed to end his life to save the world. In the ED, the patient denied every single part of the story. When I called the brother for collateral, his distress moved me as a both sibling and psychiatrist. The lawyer denied the story up and down, called his brother a liar and the favorite child, and refused to sign into the psychiatric hospital voluntarily. I felt I had no choice but to place him in an involuntary hold. It was a long and busy night, and every time I walked past his ED bay, he’d yell, “Is this the face of a crazy man? I know the law!” I tried to put myself in his position and that of his brother who had called the police. Eight is the emotional pain of involuntarily committing someone whose story isn’t black and white. Eight is the pain of exercising authority and beneficence over patient autonomy.

• 10: I was consulted to evaluate a woman for suicidal ideation whose mother had coded and died in the ED an hour before. When the woman was told of her mother’s death, she crumpled to floor, screaming she wanted to die to join her mother. In the tumult, ED staff thought she was running out of the hospital to jump into traffic. She was held in the ED involuntarily until she could be evaluated for safety by psychiatry – me. When I entered her hospital room, she was quietly weeping, whispering: “I want my mom. I want my mom.” I wanted to cry, too. I sat with her in silence for a few minutes and offered my condolences. Yet, as the consultant, I had a job to do: I needed to complete a risk assessment. My voice caught as I explained that I was here to assess her for suicidal thoughts and plans. She looked at me like I was crazy. I felt crazy. I acknowledged the risk of suicide and her expressed desire to join her mother in death. I asked the questions quickly and gently. She shook her head to all my questions and told me she just wanted to go home. I met her daughters in the waiting room who were caught up in grief over the combination of their grandmother’s death and their mother’s reaction. They seemed certain that their mother had not wanted to die, and we agreed it was a situation of the wrong reaction in the wrong place. The daughters agreed to take her home and watch her all night. This is the only 10 I’ve experienced on the emotional pain scale. I felt shame and confusion as I struggled to reconcile my obligation as a psychiatrist, and my true desire to give that woman a hug and send her home without a battery of questions at perhaps her most vulnerable moment.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at GWU. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.

A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).

Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.

I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.

A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).

Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.

I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.

A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).

Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.

I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.

Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.

Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.

References

1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.

2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.

3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.

4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.

5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.

6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.

Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.

References

1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.

2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.

3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.

4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.

5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.

6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.

Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.

References

1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.

2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.

3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.

4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.

5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.

6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.¹ The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.² Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.³ Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.⁴ Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

References

1. BMC Health Serv Res. 2006;6:150.

2. Health Policy. 2000 Oct;53(3):157-84.

3. Adm Policy Ment Health. 2012 May;39(3):200-9.

4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.

5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.¹ The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.² Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.³ Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.⁴ Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

References

1. BMC Health Serv Res. 2006;6:150.

2. Health Policy. 2000 Oct;53(3):157-84.

3. Adm Policy Ment Health. 2012 May;39(3):200-9.

4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.

5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.¹ The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.² Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.³ Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.⁴ Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

References

1. BMC Health Serv Res. 2006;6:150.

2. Health Policy. 2000 Oct;53(3):157-84.

3. Adm Policy Ment Health. 2012 May;39(3):200-9.

4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.

5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.

Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.