Have You Ever Danced With the Malingerers in the Pale Moonlight?

1:47am EST in New York, NY -- where it is unseasonably warm at whopping 50 degrees!

It's been a while since the last post. I don't even remember when that was. But currently I'm on a night float rotation, which means that I'm working at nights (6pm to 8am, to be exact) covering the entire hospital as the only psychiatrist on duty. So while I'm in this period of adrenalin-induced insomnia with ever-lingering anxiety that abounds in the midst of hoping that pager doesn't go off, here's a brand-new JK-certified blog entry!

-----------------------------

I find that part of frustrating thing about psychiatry is that it is very susceptible to manipulation by people who malinger their symptoms. It isn't uncommon at all for folks who are down and out on the streets, commonly fresh from days of drug binge, go to the hospital ER and ask to be admitted to psychiatry. Now, that usually doesn't get you an admission, so the wily veterans know that you have to say those magical words to clinch your check-in to the psychiatric ward/hotel: I want to hurt/kill myself/others. Bam! you're in.

Or at least that's the impression. The psychiatrists in training at our program get to spend a lot of time their first year at the psychiatric emergency room of the Big Public Hospital, where the admissions aren't gonna be so cheap. And often the attendings provide for us good ways to handle various situations with people who are obvious faking their symptoms, and on top of that they would back you up on the decision not to admit them just because they're saying certain magic words. For example, if you're threatening the clinician that a non-admitting decision would lead to your hiring a lawyer and suing the hospital, chances are that you're not so terribly depressed that you want to kill yourself. Just a guess, but I'm pretty darn sure.

Sometimes you can kinda trick the folks into making no sense. When you get someone who just says "yes" to every symptom you present, you can spout off some totally ridiculous ones and see if they say yes to them too. Tried this one out before, and it has worked very well. Of course, the more crafty, seasoned malingerers know to just stick to the basics, and simply repeat that they're gonna kill themselves if they're not in the hospital.

I'm probably sounding like a grouchy psychiatry resident to some readers here, and to some extent that is true. It truly is sad to see that some people's lives are so down in the dirt, that they think that they need to pretend to be insane in order to obtain warm food and a bed to sleep on. That is quite a picture of tragic desperation. But when you consider all the resources that need to be used for people who truly desperately need psychiatric care, wasting loads of it on malingering "psychiatric" patients is morally objectionable.

And it doesn't help that the psychiatrists ourselves have exacerbated this situation. At the hospital next door to the Big Public Hospital, where I'm currently working, the psychiatric ward has become a revolving door of patients who end up becoming so dependent on the inpatient setting, that they don't or won't work toward continued long-term outpatient care; a setting that truly improves the overall health of a population. Inpatient units are designed for patients who are in acute psychiatric crises, and once that is resolved they are set up with an outpatient follow-up for continued long-term care. But to so many people, the ease with which they are admitted to the hospital by the psychiatrists who ultimately make the decision to admit them, voluntarily or involuntarily, has fostered a mentality that whenever you're not feeling well, you should just go to the hospital and get admitted.

An example from this week. A man comes to the ER, complaining of wanting to kill himself and is seeking admission. I ask him about what's been going on, and he states that he was up on the roof earlier in the day, contemplating jumping off to commit suicide, but his wife went up there and convinced him to come down and go seek help. Naturally, I ask if I could speak to his wife, which throws him off a little. He thinks that she probably can't add much to what he's been going through, but in our little dance he has no choice to yield; I mean, you can't seem too suspicious.

He leaves the little interviewing office, and I call the wife. I introduce myself and ask how she thinks her husband has been doing. She doesn't think there's anything abnormal in particular about how he's been doing recently. I ask her, point blank, if she found him on the roof earlier in the day and he had to be persuaded by her to come down. She has no idea what I'm talking about.

Then I hear her cell phone ring, and she asks me to hold on. I sit in silence while hearing her speak on the other phone. Yes, I'm talking to him right now, I hear her say. Now who could that be on the other line.... She comes back to talk to me, and gives a weak endorsement about how some people get more depressed during the holidays (which I don't think has been shown to be true, by the way). I thank her and call my attending psychiatrist, with whom the ultimate decision will be made in regards to admitting this patient.

I give the attending the basic history and presentation. I tell him about the symptoms he is endorsing. I tell him about the fact that he made up a story that has been shown to be clearly untrue. Telling blatant lies for a certain stated objective is basically the definition of malingering. He doesn't seem like a desperate, depressed person in agony at all. He seems like someone who wants to achieve one thing and would lie to do it.

And the end result: surely enough, he gets admitted to the hospital. The attending tells me that we should always err on the side of caution when things aren't so clear. I'm wondering how clear things would have to get to err on the side of common sense. I'm perplexed at this point, and also somewhat outraged. There are people who need to be in the ward. This isn't one of them.

-----------------------------

There are psychiatrists who think that this is akin to being kind to someone, to admit them to a psychiatric inpatient unit even though they probably don't need to be there. After all, they are indeed desperate in many ways; just not necessarily in a psychiatric sense.

But I contend that this actually ends up hurting them. It instills a mentality that a hospital can be used as a lodging facility, when it clearly isn't and shouldn't be. It reinforces malingering by allowing it to be effective. And it directs people who need certain types of aid to a wrong place, where focus is mainly on acute mental health rather than socioeconomic well being. It's a system in which virtually everyone loses.

Come to think of it, the only ones who benefit from this practice are the psychiatrists themselves. Let's face it; if the litigious threats that abounds the U.S. medical practices wasn't present, how many of the malingerers would actually get what they want? We set aside logic, reason, and even ethical considerations for the sake of avoiding litigations. Not mistakes, but litigations. Everyone who's gone through medical school knows that mistakes are inevitable. But being sued, you see, is much more preventable. If you just cave in and play it safe, then, well, that is just the ultimate.

We do tend to err on the side of caution, and we err a lot. And these errors have definite costs, and it undermines the field of mental health. That's pretty depressing.

The Problem with "Sharing Values"

8:50 p.m. EST in New York, NY

So many Americans want people who are in touch with their reality, that of most folks in the country who work hard and hope to achieve some decent things in life: financial stability, ability to send their children to places of higher learning, decent health care, and so on.

Then why in the world, over and over again, do these folks keep voting for people who, by any empirical measure, are not in a position to be able to be in touch with them? This is Republicans and Democrats alike, but I want to look at two prime recent examples: one whom many of his supporters deemed he would be in touch with their reality, and one whose whole life shouts such empathy but is somehow maligned by many of the same people who yearn for empathy.

The former was born into a wealthy family, son of an ex-president, grew up never facing poverty, went to an Ivy League school, became the head of an oil company, a major league baseball franchise and a state governor with not much evident ability other than being born into such influential and powerful family.

The latter is a half-black kid growing up with a single mother in lower middle class standing, worked his tail off in school and ended up getting Ivy League education in college and in law school, but instead of using the proverbial "golden ticket" to become whatever the heck he could've been on Wall Street or in other lucrative positions, he returned to the neighborhoods filled with people of lower middle class or poorer standing, working directly with them to help with unemployment and other maladies that accompany impoverished areas, became a local politician and eventually a U.S. senator representing his state.

Really, which one of these folks do you think would be more in touch with the 90+ percent of people who do not have the privilege of being wealthy?

The former, of course, is President George W. Bush. The latter is Sen. Barack Obama. And it seems completely ridiculous that the aforementioned senator would get more flack for being "out of touch" and "elitist" than the president.

But how did this even happen? I don't think it's because millions of Americans have suddenly become imbecils. I think it's made possible by the claims of the politician who "shares your values." How do you do it? You get on television, tell stories about some anecdotes in your past experience that may at least look like what the "common" people may have gone through (you know, clearing bushes, chopping wood, etc.). And then you pick out certain choice issues to emphasize over and over again until agreeing on those few issues becomes equal to "sharing your values." I don't think that even comes close to helping someone have empathy for the very people they take an oath to serve, but it has gotten many, many politicians elected.

The problem with voting based on "shared values" is that it's too easy to manipulate. Words are cheap, and rhetorics can't replace decades of behavior and action. But this model maximizes the power of cheap claims and minimizes the actual hard data. Addressing to the crowd and shouting off claims that he or she believes some few, specific values has effectively overpowered a lifetime's worth of actual deeds. That's one of the big reasons we ended up with so many politicians in Washington who are loud, shallow, manipulative and without much regard for actually serving the public.

Sad.

What's So Extraordinary About Being Ordinary?

10:55 p.m. EST in New York, NY

I don't get this whole desire for a bunch of Americans (and I mean A BUNCH) to have a political leader, even the freaking president, to be an "average American." How does this make any sense at all? I don't think those same folks would want some average middle manager to become the CEO of their company of interest (whether they work there or invest in it) or want an average coach to take over the head coaching job at their alma mater's football team. But somehow, when it's the leader of the MOST POWERFUL AND INFLUENTIAL COUNTRY ON EARTH, they want someone who is "average."

Seriously, this doesn't sound insane to you? To anybody? To an average American?

The only logical explanation for it is that these folks have a different hierarchy of qualities of a political leader. Their priority would first be if they believe in the same set of values, and then everything else; you know, like ability to comprehend complicated situations, communicate well with friends and foes alike, make educated and informed decisions rather than ignorant and impulsive ones...you know, like ability to govern.

I can empathize with the sentiments of the folks who want the leader to believe in the same things that they do. But if that is at the expense of the very basic competency of doing what the leader is supposed to do, then it's sheer madness and stupidity. What exactly do these folks think a president's responsibility is, for example? Do they think her or his job is to lend them a shoulder to cry on when the country's in crisis? Are they expecting some kind of nationwide group therapy from the president and the White House staff?

Making good decisions as the chief executive of the United States, and I'm just assuming, is going to take a lot, a LOT, of intelligence as well as wisdom. There are incredibly complex things that happen around the world, and simply understanding them is only half the battle. You have to be able to come up with decisions that is good for the nation that you lead and with some foresight into the consequences, good or bad, that may come from your actions. And why the hell would I want someone "average" to be in this position? Do you want some average oncologist to take care of your cancer-stricken parent? Do you want some average lawyer to handle your legal case? So why set the bar so much lower for THE BIGGEST FREAKING JOB YOU COULD HOLD IN THE WESTERN HEMISPHERE, OR POSSIBLY THE ENTIRE WORLD?

I want my president to be above average. FAR above average, by the one criteria we should use to measure the quality of a candidate: the ability to govern.

A New Bold Insult to Women of America

9:42 p.m. EST in New York (on my brand-new MacBook!)

Much has been talked about Sen. McCain's choice for running mate, Gov. Sarah Palin, since the selection was announced last Friday. The first thought that went through my mind was not, "Wow, a Republican candidate for Vice President!" but rather "Wow, that campaign is desperate!" Talk about pandering to the highest degree to the Hillary followers, at least those in the group who consider presence of specific anatomical structures more important than what a politician actually advocates and believes in.

But more and more I think about it, the choice doesn't seem just desperate to me. It's an insult. It's a slap in the face of American women. It blatantly shows an underlying assumption that the female voters must be as crazed as an angry bull seeing red, throwing out any logic and simply acting on emotion and impulse (pretty much a standard stereotype of how women think and behave).

If Sen. McCain was once revered as a straight-talking, conventions-breaking, more or less honorable man compared to Washingtonian political weasels, this just demolishes that sentiment. This is a manipulative move, pure and simple, to get the Church of Hillary to support him -- rather, just voting for him in November will be sufficient enough. It's not a move to be more inclusive to women, but a GOP move to, yet again, exploit divisions in order to win elections.

And if none of what I've assumed and claimed above is true, then it's just an idiotic VP choice. My reasons for this assertion are as follows:

- She's not ready to be the President of the United States if something happens to the hypothetical Pres. McCain. If the McCain is going to make an argument that Sen. Obama lacks experience, how can he, by any stretch of reasonability and accountability, defend his selection of Gov. Palin? Is the Straight Talking One setting a double standard here? And the Republicans haven't only charged Sen. Obama to be unfit for command, but four years ago they did the same with Sen. Kerry, who has much more experience than either Obama or Palin. So after four short years, Palin has more qualification and experience to lead the country than guy like Sen. Kerry? Talk about flip-flopping.

- Then the argument goes that Gov. Palin's rather short-lived political experience is qualitatively different from that of Sen. Obama because she is a governor, which is an executive position. Yes, so now it seems to being a governor is an added criteria to be a qualified commander-in-chief. And what was our current president doing before he came in and nearly ran the country to the ground for the past eight years? Yes, he was the governor of Texas. That's one huge strike against governors-turned-president/vice president.

Which other U.S. presidents were governors before taking the big job, you may wonder? Notable ones include: James Monroe, Andrew Jackson, Teddy Roosevelt, Woodrow Wilson, FDR, Jimmy Carter, Ronald Reagan, Bill Clinton. And of course, W.

What about legislators, i.e. senators and congressmen? Notables include: John Adams, John Quincy Adams, Abraham Lincoln, Harry Truman, JFK, LBJ, and Richard Nixon. (Thomas Jefferson served as both a governor and a legislator.)

Looking at the list, I think it's basically a wash between the two. In other words, it doesn't seem to me like whether they were executives or legislators didn't seem to predict how well they would perform as presidents.

- But then again, Gov. Palin is the governor of Alaska. In terms of being able to assess which state's governor may transition most fittingly to govern the entire U.S., governing Alaska is basically comparable to governing Hawaii (I think they would compete for the 49th most fit position among the candidates). This is like a Major League Baseball picking a general manager from one of the smallest single-A teams (do they even have general managers?) to be the new VP of Operations. For the non-sports folks, this is like Frito-Lay choosing the manager of the Taco Bell branch in Rancho Cucamonga to be their new Vice-CEO. I think I'd rather go with a creative director (or whatever would be the equivalent of a legislator) from the company headquarter. Still, could it work? Sure, anything is possible. Is it likely to work? The probability is infitesimal. But then again, if you think Pres. George W. Bush is a good executive, this might be a very appealing prospect.

- By the way, remember Harriet Miers? She was a lawyer who served on White House Legal Counsel who was nominated by Pres. George W. Bush for the newly opened U.S. Supreme Court position. Most people disapproved with fervor, many of whom were staunch conservatives. And it wasn't because of her political positions, but because she seemed really really unqualified for the job. So where are those folks now that we have nearly the same situation for a Vice Presidential candidacy? What, so being second in line for presidency doesn't merit as much scrutiny as being one of the nine Supreme Court judges?

So how can this choice be characterized? Patronizing manipulation of the American voters, or mind-numbing stupidity? Hey, why not both? Whatever the answer is, it doesn't change the fact that this is a hypocritical decision from a campaign that has emphasized so much on the candidate's experience. Nobody votes for the VP, you say? Well, they should, because she or he is the one who will take over if any unfortunate circumstances occur. It's happened nine times in U.S. history.

Finally, a plea to the female voters of America, especially those who supported Hillary Clinton: Please don't make the mistake of voting for the McCain/Palin ticket just because it happens to include a woman. You know what her positions are, and they differ so much from those of Sen. Clinton that it just wouldn't make sense to do this. This is like African-American Democrats supporting Clarence Thomas simply because he's black. Don't willingly take a step back after marching forward through all these years. Gov. Palin won't add to the much-fabled 18 million cracks in the glass ceiling; she will replace it with a brand-new one.

The Olympics Quick Hits, Part 2!

2:02 p.m. PST in Rancho Cucamonga, California

I knew I left out some thoughts from the last post. For your non-sequiturious pleasure.

-----------------------------------------------------------------

Just to insert some crassness into this post, the hottest athlete in the Olympics is Lolo Jones, the 100-meter hurdles specialist who would have comfortably won the final race yesterday if she hadn't tripped on the penultimate hurdle. So sad. More sad than when that Chinese dude in 110-meter hurdles pulled out. I know that sent like 1 billion people sobbing in China, but it's hard for me to do that because: (1) I honestly have never heard of him before, and (2) he doesn't look like Lolo Jones. This is yet another evidence in my assertion about biracial people being attractive, although she's not half-Asian (I don't think). I guess it also helps if they are also a track star.

-----------------------------------------------------------------

Then there's the most adorable athlete of the Olympics: Shawn Johnson, a U.S. female gymnast. When asked to describe herself a few years ago in an interview, she said that she was a "daredevil with a big smile." Even that comment is soooooo adorable. She has been the one competitor in the U.S. team that has been consistently great throughout the whole Olympics, although she didn't stick the dismount too much; that would be Nastia Liukin, who edged her out in the women's all-around title. She finally got a gold medal though on the balance beam. And you could see that although she is probably looks most harmless in competition, she is pretty damn fierce and thrives under pressure. When they showed her parents hugging and crying together when they realized she will win the gold, I teared up as well. No, not at the level of the entire China crying about that Chinese dude (see above for picture) who couldn't run the hurdles. By the way, I think it's good that these girls don't have so much makeup put on their face that they look like child prostitutes. Yes, I said it.

-----------------------------------------------------------------

Bela Karolyi should be involved in every gymnastics telecast ever until he dies. There should be a live feed dedicated to him, just to see him watching the events, particularly when U.S. women do their routines. It has been the most entertaining thing in the Olympics so far, and it will remain to be so for the remainder of these games. And he's no hack either. He's a legendary gymnastics coach, and has been involved in perhaps the two most memorable Olympic gymnastics moments in history: Nadia Comaneci's "perfect 10" performance, and then Kerry Strug's sprained-ankle vault in 1996 that sealed the deal for the team gold medal (he was the guy carrying her around, remember?). Watching Bob Costas play off of him during the broadcasts was pretty awesome, as Costas is one of those rare sportscasters who can make fun of his colleagues without make it offensive or insulting.

-----------------------------------------------------------------

By the way, if you think those Olympic sprinters are fast, how about those cameramen who right next to them the whole way at the same speed without even having their equipment shake up and down? Now THAT is quite a skill!

-----------------------------------------------------------------

So I understand that beach volleyball is really popular for the same reasons that "Baywatch" was really popular, but have you seen men's indoor volleyball? These guys really hit the crap out of the ball! And so much more strategy involved compared to the beach volleyball, that for the pure athletic spectacle I don't think they are even in the same echelon. Plus, there are lots of countries that are really good at it (unlike beach volleyball, which seems to have a few dominant teams that always win), so it's more suspenseful.

-----------------------------------------------------------------

So NBC made this "top 10" list from "Dr. Nancy Snyderman" about how to cope with having to stay up late to watch their Olympics coverage. I think it was mostly tongue-in-cheek, with suggestions that include convincing yourself that four hours of sleep per night is enough, and basically saying "screw work, Olympic games come around only every four years!" Hmm, how about doing lots and lots of cocaine? Or better yet, BROADCAST THE DAMN GAMES LIVE!!!!!

-----------------------------------------------------------------

That's it for now. I think.

The Olympics Quick Hits!

4:41 p.m. PST in Rancho Cucamonga, California

None of the usual protracted musings. It's time for Quick Hits, the Olympics Edition!

---------------------------------------------------------------

"People"'s "Republic" of China showed us, through its stupendous opening ceremony, that there is little a nation can't train/coerce people to do in authoritarian regime. I mean, there is no way such things can be duplicated in London. They won't even by able to get 28 people to do things in synchronous motion, let alone 2008. TWO THOUSAND EIGHT! Hence what we witnessed will never been outdone...until North Korea gets it's Pyongyang Olympics! For get 2008 people, they will get the entire country to do whatever it commands. At the least, they would do a kick-ass recreation of Michael Jackson's "Thriller" video (even better than those Asian prisoners on YouTube).

---------------------------------------------------------------

Michael Phelps is awesome and all, but it seems unfair to call him the greatest Olympian of all time based solely on the number of medals he's won. It just seems to me that there are way too many medals in swimming in general (I think there's close to 40 medal races there). And you have four different stroke styles that essentially quadruples the number of medals. And yeah, three of the strokes are more or less derived from "natural" ways in which people swim: freestyle (obviously), backstroke and breaststroke. But butterfly? Who the hell swims that way if it wasn't in a swimming competition?

Maybe track competitions can learn from this. In addition to 100-meter sprint, we can have backward run, skipping and hopping. And you could have boxing matches that go in different lengths: 1 round, 2 rounds, 3 rounds, etc. I mean, that's what happens in swimming and tracks, right? You can have like 10,000 medals in these games!

---------------------------------------------------------------

Gymnastics. I for one like the new way they're doing the scoring, because it clearly makes the differentiation between degree of difficulty and execution (no, not that kind of execution, although they are in China...). This way, you don't have a gymnast do a relatively easy routine perfectly and get a perfect score, which is kinda cheap.

But what's with the brutality in the execution (not that kind) scoring? Where the heck are these deductions coming from? Obviously I don't have trained eyes in this, but even the performances that seem perfect are getting scores like 9.4 out of 10. So where are the deductions coming from? And I like how the NBC commentator uses the phrase, "visible errors." Are we supposed to be on the lookout for invisible errors? Do these judges have some special ability to see errors beyond the capability of normal human photoreceptors?

And what's with the age limit thing? I thought the whole scandal is that they are supposed to be 16 or older, and yet on the telecast I see several female gymnasts who ages are shown as 15. Is that their real age?

---------------------------------------------------------------

I won't even go on a rant about the strategy NBC is employing for its broadcast, except that I was really looking forward to watching the games in the Pacific Time Zone during my vacation (which happens to fit perfectly with the two weeks of competition). See this way, I get to start watching the prime time telecast at 5 p.m. and then go to sleep at like 11 p.m. This is actually the biggest reason I miss living in the West Coast; sporting events happen three hours earlier than in the East Coast. I can wake up Sunday morning, saunter over to the living room, slump down on the sofa half-asleep, turn on the TV and BOOM! Pro football is on. So awesome. Same thing on Saturdays with college football, and plus you get one extra game in the afternoon.

Thanks for shattering my dreams, NBC. Perhaps for the next Olympics I should just go to London. Grumble grumble. And there's the rant that I said I won't go into.

---------------------------------------------------------------

I know the "Olympic Spirit" isn't about winning and losing, but come on. When the nations are constantly updating their medal counts (and so are the networks), can you really claim that? And if it is going to be a significant part of the games, there should be a better way to say who "won" the Olympics. I was living in Korea during the 1988 games, and the way Koreans ranked the nations in medal count was by the number of gold medals, while silver and bronze were only used as "tie breakers" if there were same number of gold medals among multiple nations. By this logic, having 1 gold medal and no other medals outranks having 100 silver medals. That seems stupid to me, but it's kinda American way of thinking in a way, isn't it? For example, the Buffalo Bills, who went to four straight Super Bowl games in the early 90's lost all four times and are derided for it. If they had won one championship and yet never even make it to another Super Bowl, would they be considered to be better? Hmm....

Then at the other end of the spectrum, you have countries that just count the total number of medals. That also seems illogical, since obviously a gold medal is worth more than a silver or a bronze by definition. So I think there should be a points-based system that gives 5 points for a gold, 2 points for a silver and 1 point for a bronze. You tally the points up, and there you have the winner. But of course, people cannot stand simple arithmetics to interfere with their entertainment, so this probably won't fly. Tsk, tsk.

---------------------------------------------------------------

Lastly, this blog article was written by another guy, but he was considered too ugly to be seen to have written it. The most confusing part, of course, is why they got me to "finger-synch" for him, considering that my looks peaked at age 5. But still, have you seen this guy's teeth? Totally inappropriate for blogging.

Psychiatry After Dark, Part One

4:34pm PST in Rancho Cucamonga, California (where dry heat rules!)

Prior to the present state of vacation back home-home and the unlimited supply of do-nothingness, I was doing night float psychiatry for two weeks at one of the community hospitals in NYC (not Bellevue). What is "night float," you may ask? It's when you're working at night exclusively, in this case from 6pm to 8am. Thankfully I was only responsible for four nights a week, from Monday to Thursday overnights. It's a pretty singular experience, covering the psychiatry floor (the least busy part of the rotation), the emergency room consults (the busiest part), and being available for emergent consults for, well, the rest of the hospital, which was surprisingly uncommon during my two-week tenure. Some of the highlights included the following.

----------------------------------------------------------------

- A dude takes a cab from home to the ER after he cut into his scrotum with a knife in an effort to de-testiculate himself. I'm pretty sure that's not a real word, but you get the point. So he's sitting in the ER and I get a call, stating the nature of the consult. The first question from me: Um, is he going to have a surgery? ('Cause you know, psychiatrists don't fix, um, deflated balls.) They say he's getting prepped to go to the operating room any minute now. Well then, why don't we consult the actual psychiatric consultation team--you know, with actual consultation specialists and all--AFTER the surgery? 'Cause as much as it would be important to figure out what was going through his mind, it would be pretty important to make sure his testes don't fall out.

Two hours later I get paged from the ER, about the same guy. It turns out the trip to the OR was delayed a bit because they wanted him to get a little more hydrated through the IV line. So I get about 30 minutes to see the guy at 2am, asking him about why he decided to slash his scrotum. And yeah, it was a pretty amusing 30 minutes of psychiatric interview. He pulled the same thing once before 10 years ago, and the reason was the same: he just did not want to have his primary sex organ anymore. He said they make him "want things [he] can't have" and may "get in the way later" when he may choose to have a sex change. So he carried out this plan in his bedroom with a kitchen knife, and when the pain and the bleeding got too much for him, he decided he was doing something that was "really stupid" and took a cab to the ER. By the way, he lives with his mother, who was sleeping in the next room, and didn't bother to wake her up because, well he didn't want to bother her. Hmm.

Long story short, he went to the OR, the urologists fixed him up, stayed on the surgical floor for a few days, and then got transferred to the psychiatric unit. With his anatomy intact. Yaaaaay.

- A tale of two malingerers. One was a guy who had a great script for reasons he just had to get admitted to the inpatient psychiatric unit, delivered even before I finish asking him what's going on. Then the classic malingering signs show: (1) he can't answer questions without being vague, (2) he tries to evade answering questions about pretty much everything, (3) he hides any sources of collateral information (e.g., his family), and (4) he gets defensive and hostile further the interview goes along, but without any sign of mania or psychosis. The clincher was when he said that if he gets sent out from the ER without being admitted, he will eventually return to the hospital with a lawyer because he will have done something to hurt himself. Bluff called, and that's an ejection from the hospital.

Then the next guy, who is a homeless veteran. Very sad, but I still have to do my job. First I get an opportunity to watch him, without his knowing, interact with the nurses during the intake interview. His reason for coming in was depression and active suicidality, but already the guy looks nothing like a depressed person. He makes his own bed and comfortably lies down and changes the channels on the TV set, muttering to himself, "Now that's what I need." Yeah, the guy doesn't stand a chance. I see him a little later, and he is just hopelessly vague and evasive. He doesn't volunteer any symptoms of depression, so I start listing some legitimate ones. And then I throw in some bogus symptoms: "Do you feel like the walls are caving in?", "Do you see little green men?", etc. So when he enthusiastically agrees with them, I'm just gathering up more and more bullshit to document. Then he lists off a couple of medications that are in no way used for treatment of depression. I ask him how long it takes for the meds to work, and he answers "immediately." Then I suggest that I would give him a dose tonight, and then refer him to a clinic for the morning, to which he most unshockingly objects. A minute later, he corrects himself, saying that he misspoke about the drug working immediately, but it actually starts working a few days into the treatment. Of course. And to boot, he hides the fact that he has had a long substance abuse problems, which I confirmed after getting a collateral information from a colleague of mine at the VA hospital (with his permission, of course). Not good, not good at all. For him, at least. At least he didn't really get so hostile. He's ejected as well.

The thing is, I do feel sad for these two guys, and people who malinger to get admitted to the psychiatric ward in general. I mean, think about it; how much does your life suck for you to come to the point where you feign having a mental illness and get admitted to a locked unit, just to sleep in a bed and eat three square meals a day? It really is sad, but one of my job is to treat people who would benefit from what my field can do for them, i.e. those who are truly mentally ill, whose need isn't satisfied solely with a mattress and hot food. And it does bother me that they lie about having suicidal thoughts, psychotic symptoms, and whatever they muster up. It's offensive to the people who actually have those problems and struggle with them. And plus, I don't really like being lied to, especially when I know that I'm being lied to. So sorry to the psychiatric version of GOMERs ("Get Out of My Emergency Room").

- The most pleasant thing about doing ER consultations, I must say, is when I run into people who really have need to see a psychiatrist (or at least some mental health professional) who do not need an admission. I saw one man who got out of jail a year ago, struggling to pay off his family's debt, and ended up relapsing on heroin two weeks prior to the visit after he was turned down repeatedly from jobs he is qualified to have, solely because of his criminal history. He felt like he is just have too much stress to handle in his life and also felt like he needed to talk to someone about his renewed drug habit. So it was my pleasure to provide him with an impromptu supportive therapy of sorts, which lasted about an hour and a half (thankfully I didn't get paged away during that time). I encouraged him to go to the clinic to which I referred him, and to work with someone about his drug habit. He said he felt "much better" after just being able to talk truthfully about the hardships in his life. I can definitely empathize.

Later in the week, I see a man in his early 20s who has been in hospitalized for psychiatric treatment more than a dozen times during his teenage years, but hadn't been hospitalized in the past three years because he has been receiving once-a-month injections of an antipsychotic medication. But in the past two months he stopped going to the clinic to receive the medication because he thought he was fine without it. Time for some education about the purpose of the medication, which is not only for relieving the active symptoms of psychosis but also to decrease the risk of its recurrence. He was somewhat receptive to it, but I sensed that he was hung up about having been diagnosed with a mental illness, which carries with it a hefty load of social stigmata and skewed views, so easy to be internalized by the mentally ill themselves. I made a comparison of his psychotic illness with heart disease, diabetes, high blood pressure, and epilepsy, with the bottom line being that it is a legitimate illness and it needs regular and continued treatment to prevent an adverse event from happening as much as possible. Finally he was convinced and agrees to start back on meds, starting that evening at the ER.

It certainly does feel good to have made some kind of immediate intervention. For all the jokes I make about "saving lives," this is about as closest it has gotten for me in psychiatry so far. Not just managing crises, but making an intervention that hopefully would change the course of the patients' attitude about themselves and their treatment, hopefully for a long time to come. Even more reason I suspect I would really like outpatient psychiatry.

----------------------------------------------------------------

There's more, but those are the highlights. Now to go back to doing nothing....