Tuesday, May 12, 2015

Adventures in the Veterans' Hospital Mental Health Clinic - Last Part

This post continues on from my post of 4/28/15 about the practice of psychiatry in the outpatient mental health clinic at the Veterans' Affairs Hospital in Memphis, from which I retired a few months ago. In the last post, I discussed the first of two reasons for my quitting my position about a year earlier than I had planned.

The issue of being short staffed relates to the second issue that caused me to abruptly curtail my expected period of employment with the VA. That will be the subject of this post.

In line with recent trends everywhere in psychiatry, the MD's on staff at the VA were basically not expected to do regular psychotherapy but were there only to write prescriptions for psychoactive medication. This policy was of course never clearly spelled out, but everyone knew it. As mentioned before, however, there were nowhere near enough Ph.D. psychologists to provide psychotherapy to all who needed it.

Furthermore, there were no psychologists on staff who specialized in what I specialize in, the individual psychotherapy of borderline personality disorder (BPD). Such patients are not at all uncommon in the VA population. The clinic did provide some of the "skills-training" therapy groups that are but one of three parts of a treatment known as dialectical behavior therapy (DBT), but even the DBT purveyors' own studies show that the groups without the individual psychotherapy component of DBT are not very effective.

I was able to provide regular psychotherapy for two of these patients anyway, but only because one of the doctors on the inpatient psychiatry unit was having a lot of trouble with these particular ones. Their behavior was creating significant problems on the ward, and additionally they were using up a lot of resources. 

The inpatient doc literally begged my supervisor to accommodate my schedule in order to allow me to see them regularly, and she reluctantly agreed. Of course, if I had been the one to ask for psychotherapy time for a patient I was seeing, it was highly unlikely that such accommodations to my schedule would have been forthcoming.

Then one day there appears a note in the electronic medical record for one of my medication-management-only patients with BPD, alerting me to the fact that she was making vague suicide threats. Luckily, I knew the patient fairly well, and surmised that she was probably just reacting to her frustrations at the limitations on her own treatment at the VA, and was probably not an imminent suicide risk.

But then I thought: What if she had been? In such a case, there would have been a note in the chart advising me of a potentially life-threatening problem for which I was technically responsible, but which I was not being allowed to actually treat. And there would be no one else to send her to so she could get adequate treatment. 

Inpatient treatment could buy time if the suicide risk were very high, but it usually causes patients with BPD to get worse in the long run, and is therefore best avoided except in extreme circumstances. And one still needs to refer the patient for continuing psychotherapy after discharge. That was the very problem the inpatient doctor had with my two therapy patients!

In response to the warning about the patient I had received, I documented my dilemma in the patient's electronic medical record - consequences be damned. I then finally admitted to myself that I had to get out of the VA very soon.

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