My Best Dumb Lawyer Comments

It is no secret that doctors are not fond of lawyers. I do not hate all lawyers. I have met some very nice ones in my life. The ones that helped us close on property we bought and the one who helped us write our wills; those guys were okay. I hear that lawyers that represent families battling schools that are not providing appropriate services for their children with disabilities are pretty nice people. We deal with laywers in the risk management department who advise us on issues of medical ethics and cases that can be rather messy. Those lawyers are decent people. It is the malpractice lawyers that really tic doctors off.

I have not had the misfortune of ever having to deal with a malpractice case, and psychiatry is actually a low risk field for getting sued so we do not worry quite as much as, say, a surgeon or obstetrician. The lawyers we deal with and really get into conflict with are public defenders who work with patients in involuntary committal hearings and disability attorneys.

Disability attorneys annoy us for the reason that they are constantly pressuring us to fill out paperwork to declare patients permanently disabled who are not, and need to get a job. Some psychiatric patients need disability and are never going to be able to handle the stresses of a full time job, but most of them are capable of working, and really should. Being on disability is a barrier to getting well in fact. If one were to get well, one looses his source of support and faces an uncertain job market. Worse then that, he has to go to work and some people do not have the best work ethics in the world. Many people have gotten into the rather bad habit of watching a lot of TV and playing a lot of video games and are none to excited to change that pattern. I hate to say it, but it is true. I have worked in many states with very different types of communities and have seen this happen everywhere.

The other type of attorney that really gets psychiatrists goats is the public defender. Not that they are always bad, but for the reasons that we need to work with them. No psychiatrist enjoys committing a patient against his/her will, but sometimes it is necessary. The laws are much more strict than in the past to prevent abuse of patients, and if it is felt that a patient needs to be hospitalized involuntarily, there will have to be a hearing of some sort. Each state's rules on how this is done vary but have some similarities. One is that the patient has a right to be represented by an attorney, which most of the time is going to be a public defender. I would never imply that a patient does not have the right to appropriate legal representation in a committal hearing, but I will never attempt to commit a patient unless I truly feel that the patient is putting him/herself in danger by not receiving treatment or is a risk to society. Some PD's will see when a patient is really sick and not try to secure a really sick patient's release solely to say they won the case. These ones will often know when releasing the patient is going to potentially have very disastrous consequences (suicide, homelessness, bankruptcy, loss of home, family, life savings, etc.) and will not push too hard because often the patient is too sick to realize the risk him/herself. This is very commonly why we are seeking commitment in the first place. To try to help a patient with poor insight before he ruins his life and kills himself. Some PD's will fight to the death to get the patient released at all costs, regardless of how ill the patient is or how obvious it is that the patient needs treatment. Often in the case where the PD sees that he is fighting a losing battle, will start to ask rather ridiculous questions in order to catch the doctor off guard, often making himself look like an idiot in the process. I love those moments. I keep them cataloged in a special cubby hole of my mind to be brought up again at unit Christmas parties and anytime someone looks like they need a laugh.

Some of the best:

PD: How do you know the patient's homeopathic medication is not effective at controlling her symptoms?

Me: Well, she is here, isn't she?

PD: So you say that the patient could not come to the hearing because he refuses to wear clothes?

Me: Yes, that is correct.

PD: Is that a problem?(Not if he were Daniel Craig, but he was not, so yes.)

As a side comment, a social worker at the hearing who knew the patient told the PD "trust me, if you had ever seen him, you would know, yes, it is a problem."

PD: Tell me, if the patient's delusions were to turn out to be true, would she still need to be committed?

Me: Well, no, then she would not be mentally ill.

PD: Why do you think this man is a danger to his son?

Me: He is well established as an alcoholic and has been court ordered not to drink around his son, which he still does. Also, he has held his ex wife at gun point more than once and threatened to kill her.

PD: What makes you think that just because he will willing to kill his ex wife that he poses any danger to his son? (Maybe beecause he is a sociopath?)

PD: Exactly where is the danger in what she was doing that night?

Me: She was walking in the dark in a neighborhood with numerous "shooting galleries" and crack houses where there was a high risk of dirty needles being on the ground. She had no purse, cell phone, money or means of defense. She was barefooted. This is a high crime area where she is just a likely to be kidnapped and raped as be held up at gunpoint by a desperate addict seeking money for a fix. She had not slept in three days and was confused and had no idea what kind of danger she was putting herself in.

PD: Yes, but what has she done that is a danger to herself?

PD:You say that the patient has left the hospital two times before with a court order to take his medications and did not anyways. He told me that he would take his medications after discharge this time. What has he done to give you any indication that he would not take his medication after he was discharged? (If that was not proof enough, I had to respond.)

Me: He told me he was not going to take his medication after discharge this time. Has it occurred to you that he may have lied to you?

I save the best for last:

A big headed PD who had visions of being the next Perry Mason was trying to make me look bad during an appeal hearing by questioning my credentials. This is how this proceeded:

PD: Are you a licensed psychiatrist in the State of Pennsylvania?

Me: No, I am a licensed physician in the State of Pennsylvania.

PD: Whoa,whoa,whoa, now hold on there! Can you please explain to the court just why you are not a licensed psychiatrist in the State of Pennsylvania.

Me: Because there is no such thing as a license for psychiatry, we are physicians and licensed as such. I am a Board Certified psychiatrist if you have any concerns.

PD: (defeated) I have no further questions.

Me: In my head I was thinking "Can you explain to the court just why you are not a licensed dumbass in the State of Pennsylvania?" but I kept my mouth shut.

We had a really good laugh over that one. This attorney has since moved on to bigger and better things in the legal system but he continues to this day (even though this was years ago) to bear the moniker "Licensed Dumbass". When there was a hearing scheduled on the unit, the question, "Is the licensed dumbass defending today?" was often overheard. This is a fact that he may, or may not know but if he does, I really do not care. If the Foo Shi......

By the way, the licensed dumbass lost the appeal.

White Coat Dilemma

One can call it tradition. One can call it habit. One can call it dogma, butone fact remains clear.

Psychiatrists do not wear white coats.

We are the only field of medicine where this is a consistent situation. While some non-clinical fields like radiology or pathology may find persons who do not feel the need to wear a white coat, head shrinkers will not wear white coats even if told they are supposed to. It is not done. Period. Some residencies go so far as to forbid the practice. Emory University is a highly respected residency and does not allow residents to wear white coats, even while completing inpatient rotations. I do not wear one even though I work exclusively on an inpatient setting, and to be honest, could really use the pockets. But I do not and refuse to change my mind.

Why? The official reason is because white coats are too clinical. Psychiatry has a history that, in truth, was not always that pretty. We are not afraid to admit our legacy of excessively long hospitalizations, mistreatment of the patients and ineffective treatments that could in some cases put the patient's life at risk. These days are long gone now and we no longer wish to be associated with the overly authoritative image of the white coated doctor who came in with an emotionless face and sentenced a patient to whatever treatment he felt would somehow fix the patient of his/her ill defined ailment.

The other branch of psychiatry that existed was the psychotherapeutic arm where analysts in suit coats analysed patients lying on couches. The usually affluent patient unloaded all of her inner traumas until some resolution of their problems was arrived at. No white coats. Dated, but still much less threatening, nonetheless.

As a side note, for those of you that have come in contact with several, especially older, male psychiatrists, you are not imagining things. There is a large population of psychiatrists that cultivate the Sigmund Freud look. Most of the men that bear this look are older and trained back in an age when psychiatrists actually did do psychotherapy and used the principles of psychoanalysis in their daily work. I am not sure why, and I really do not have the guts to ask. Maybe I do not want to hear the answer. I am not afraid of the wordy "psychobabble" response. I am just as good at dishing one of those responses out as any other psychiatrist, and actually would know what was being relayed to me. It is a fear of angering the ancient legacy of the "great ones". Much like the curse of Tutankhamen, one does not dare question the past teachings of the old psychoanalysts lest one risk some horrible fate befall him or her.

Returning to the white coat issue, this one is common to all psychiatrists, older and younger, male and female. Psychiatric units are also often regarded differently in that the nurses are often allowed to wear street clothes rather than nursing uniforms. Lately, there has been a movement to have them wear uniforms but the more traditional people, myself included, are opposed to mandating this. This is for the very same reason. Nursing uniforms remind too many people of the evil nurse behind the window in "One Fell Over the Cuckoo's Nest", with her cap and curt dress and tend to be too threatening. Obviously, nursing uniforms have changed quite a bit, looking more like surgical scrubs today, but the connection is still there. Do not even think about asking a male nurse to wear one of those caps. The nurses at my hospital are very quick to respond to my requests and have a very rigid pecking order where the doctor rules. This strict order makes me feel to some degree uncomfortable, but this might be the one time in my career that I would risk getting backhanded.

On a deeper level, psychiatrists like to be the rebels of medicine. They will not say this, but there is that undercurrent. Touching a patient is considered a boundary violation in therapy and while it does sometimes have to occur while working with inpatients, effort will be made to avoid it. Many hospitals actually have psychiatrists examine each others patients to prevent them from actually coming in direct physical contact with their own patient at any time, even in a clinical setting. This is not rebellious, it goes back to the very rigid boundaries that need to be kept to maintain a healthy therapeutic relationship with our patients, but it does make our relationship with our patients much different than other medical fields that provide direct medical care and helps to define us as somehow "different" from other fields of medicine.

In a similar vein, we do not wear stethoscopes, carry oto/ophthalomoscopes, reflex hammers or penlights. Our patients wear street clothes while in the hospital and are expected to be able to get up, go to groups and eat in a general area. No IV poles, electronic beds, heart monitors or oxygen masks allowed. If the patient requires these sorts of treatments, they are not ready to come to our unit yet.

Since our units are different and our treatments are different, psychiatrists tend to be different. Hospital rules tend to require shoes not have open toes, women wear hose, men wear ties, etc. The usual office dress code. They tend to discourage excessively high heels, long necklaces, multiple rings on a hand, more than 1-2 piercings per ear (certainly nothing besides the earlobes, and no lobe dilators). These rules have a tendency to be viewed as "suggestions" by a lot of psychiatrists. I did not have the guts to show up to work with biker boots like a former medical director once did, but I live for my malignantly high heeled sandals and do not handle hose when the temperature rises above 60 degrees. I do not fear my blatant disregard for my consistent violation of the no open toes rule. Or the limit of two rings per hand, two earrings per ear (I have three on one, so I am not really that bad) or not dangly earrings/necklaces policy. A lot of men I know have long forgotten about the tie as an accessory. None of us worry about retribution. I have always said, if someone in administration says something about the way I dress, I will change my errant ways, but only if someone does.

Except for the white coat. I will not wear a white coat. Shrinks do not wear white coats.

The Lunch Room

In the last post, I alluded to the discussions that occur in the conference room at lunch time. Our unit is small and the conference room doubles as a lunch room. The designated lunch room is too small and too cold for most to tolerate. The staff of a psychiatric unit is more constant than med-surg because it requires a different kind of knowledge to work with this patient group, so the staff get to know each other pretty well. Lunch conversations can get rather, well, interesting to say the least. Among recent topics covered:

Who amongst us was the biggest nerd in high school.

Who had the most dysfunctional family while growing up and what they are like now.

Naughty things we did while in high school/college that we were not too proud of. Children of dysfunctional homes do tend to have rather rebellious pasts and those who fit into this category were not different.

Naughty things we did that we were proud of.

Amazing feats of nature that one can accomplish if one is intoxicated enough. In a related note, amazing feats of shear stupidity that can be accomplished in intoxicated enough. We put that park bench back, by the way.

Naughty things that we would probably be doing now if we did not have a reputation on the line to maintain.

What our naughty things were: sex, partying, skipping school or stealing park benches.

Reminiscing about past road trips to various college football bowl games and the debauchery that occurred during said road trips.

Who is most deserving of a swirly: Glenn Beck, Sarah Palin, the CEO of BP or Dick Cheney.

Who is most deserving of a total ass whooping: Ben Rothlissberger, Chris Brown, Rush Limbaugh, or Paris Hilton.

What is more boring: CSpan II or Mitch McConnell on one of his "tirades"?

That Fox News is nothing more than a bastion of right wing propaganda headed by Rupert Murdoch and that the staff members who come in with all the delusional sounding horror stories about what is going to happen in health care need to stop watching that station.

New and more creative ways that our patients have found to abuse prescribed medications.

The most hysterical thing a patient has said to us in the past 24 hours.

The most hysterical thing our children have said to us in the past 24 hours.

How we responded when an angry patient called us a tramp/asshole/douche/MF'er, etc.

How we would have liked to respond.

Jokes about who present in the room is most likely to have a pair of leather pants with the butt cheeks cut out, handcuffs and a cat o'nine tails.

Speculation on who owns the two Ferraris that park in the doctor's lot and how I can coerce said individual to letting me drive one of them.

Asking about just exactly did BP intend to do about all those walruses in the Gulf of Mexico?

How disgusting some of our patients tattoos were.

If anyone staff had a tattoo. If so, where it is and what it is. Most of the time, the tattoo NEED NOT be revealed, please. Usually there is the usual discussion about how that dragon on one's butt at 30 is going to be a walrus on the back of one's knee at 80 and then the owner is going to look like a real douchbag. Of course, if that person were to go swimming in the Gulf of Mexico, he could rest assured that BP would protect him.

The conventional wisdom states that one should never discuss religion or politics in a public venue. Both of those topics do come up in the conference room setting and seem to usually get discussed peacefully, although beyond the above mentioned discussion about swirlys and Fox News, the level of discussion tends to be superficial. There are a few topics that are never discussed under any circumstances. To bring these up would most certainly destabilize the fabric of the universe and cause most certain disaster. They are:

Whether or not anyone actually does own pants with the butt cheeks cut out, or related type items.

Personal opinions on the nurses union by anyone who is not a nurse.

Specifics about one's salary.

If one owns any stock in BP.

The Inside of Depression

Severe depression is a monster the lurks in darkest regions of the mind. It slowly eats at the sufferer slowly, draining her of her strength until only a speck of the person she truly was survives. She is a lost soul, caught in a deep well that she cannot escape and feels powerless to change her situation. They have a feeling of weakness, desperation and pain that others do not always understand. Comments from friends and family to "just get over it" or "just pray harder" only serve to worsen the pain and make the sufferer feel more helpless as every effort she makes fails and damages her weak self esteem further. At times they find the pain so unbearable, that thought of death and suicide do seem like the only option to relieve their suffering. Most people will fight this choice, but many will make attempts. Fortunately, most will fail. Sometimes they succeed, leaving a lot of questions and grief in the survivors of the lost person. But sometimes a person is just done. She has had all the agony she can take and cannot go on any further.

Patients describe what they are feeling in many different ways, but they all have a similar feel to each other. There are milder cases of depression which are far more common. And there are the ones that reach the point of desperation like this.

A very wise supervisor of mine once told me that people do not want to die, they just want the pain to end. I have told this to many of my patients who have made serious suicide attempts, and they for the most part relate to that statement. Depression is a pain that cannot be seen and although it is hard to judge the extent of physical pain a person may be experiencing, there are objective signs that can be observed to give one an idea of what the patient is feeling. There are signs of severe depression, but sometimes they are more subtle. A trained eye can pick them out better than a lay person, but there are times when the sufferer can hide the pain well enough that the amount of emotional despair they feel is not evident. I have had patients that have committed suicide that did surprise me, but most of the time, I saw it coming. Some people will never be cured fully and the best treatment available will not help all. Cancer is a lethal disease, and depression is, too.

Patients have described what they feel in various ways. Severe depression is hard to explain. It must be experienced first hand to truly understand the full intensity of the suffering one can feel so they rely on metaphors to relay their feelings.

I have heard the monster analogy repeatedly, or the description of a demon controlling a person's soul, a vampire like creature draining the life from a person slowly.

I have heard about the feeling of being lost in a tunnel with no light at the end and no hope of rescue. Of being in a deep hole, unable to climb out, trapped and no one is there to come to one's rescue.

I have been told of feelings of being unable to move, feeling like one is walking through gelatin or heavy syrup, or rigor mortise. Technically called leaden paralysis, difficulty with slowed motor skills is noted in some variants of depression.

They speak of having their brain slowed down. Unable to process information or think. Like their mind has shut down and is moving in slow motion. They cannot concentrate or stay on task. In fact, there is some truth to this. It is believed that part of depression is cause by the decreased production of some neurotransmitters, the compounds that the brain uses to send its signals. The brain essentially is running too slow.

Some talk about having a coating on their brain cutting them off from reality, like a thick syrup or paint that closes them off from reality. Some even feel like their eyes have been covered by a haze that clouds their vision.

The most severe forms of depression are accompanied by psychosis where the patient loses touch with reality and often develops paranoia about friends and family. Trying to talk with them can be more difficult because the paranoia is so pronounced and patients have a hard time trusting the people they have come to for help. They are often tormented by voices telling them things and cannot always distinguish what is real and what is not but the voices will often tell them that people are trying to harm them

Depression can be treated, although sadly, most cases are not treated to remission, either due to lack of aggressiveness on the part of the provider, non compliance with the patient or both. If the initial case is not treated to remission quickly, the patient may never fully recover. Even for those that do fully recover, the chances of relapse is well over 50%. Returning to treatment is often successful, but only if aggressive and the patient may need to accept the idea of remaining on antidepressants for life if she does not want to run the risk of another relapse.

The monster can be controlled, locked away in a dungeon and possibly ignored for a time, but once someone has been overtaken by the monster, it will always be there with her. The threat that the monster will return will always be there, as the likelihood that it will escape its cell is high. Even if it never does, the sufferer will never forget the experience of being controlled by another creature and the memory will always be there. The victim will have to carry that "what if?" fear forever because she knows, the monster lurks.

For the College Graduate

Every year NBC News has a medley of college graduation speech clips and one of the clips struck a nerve with me. The comment was something to the order of "You do not need to make anybody proud but your parents, and you have." That statement bothered me because I know it is not true. The only person a college graduate needs to make proud is the college graduate him/herself. Sometimes, the graduate has no one else. Sometimes he does and those people are not supportive or simply just do not care. No one should ever say that graduating from college is not a laudable achievement, but there are times when the only person who celebrates that achievement is the graduate.


Lunch in the conference room on the psychiatric unit here can be interesting. It is not unusual for the converstation to deviate to the "my family was more dysfunctional than yours" competition. Mental health workers often go into the field because of a past history of experience in the area, either personally or with family members or both. Dysfunctional families are not uncommon. We have plenty of staff who did not have a firm support system to get them through high school, college or even further education.


Not every successful professional out there comes from a stable home. Some people had the strength of character to fight the battle to get an education and a solid future solely out of their own desire for a better future for themselves. It is not an uncommon maneuver to get married young to get out of an abusive home, but there are some people who have the sound minds to graduate from high school as quickly as possible, go off to college in a town far away and get an education. For some, proving their parents' assertion that they will never amount to anything is almost an act of rebellion. Some of these people are not the most emotionally stable people in the world and have a tough time surviving, but are smart and fight their way through. Some were lucky enough to have some kind of mentor to help them build up some kind of self esteem. A lot need a lot of Prozac and years of therapy before they truly feel confident in their abilities, but they pull through and often, become the kind of people who help those children who do not have a good support system at home.

We were joking about how disgustingly soppy the Mother's Day cards available tend to be and how often they just do not fit the occasion. Many people love their mothers, they gave them life after all, but do not have the kind of loving, entwined relationship these cards often seem to portray. Some of the sentiments that were toyed with for more appropriate cards were pretty hysterical:

Die!

You were sometimes verbally abusive, but you taught me how to get away with speeding, made sure I got a good education and how to check my motor oil level. Thanks Mom.

Mom, you put me through Hell but I am glad to be alive so thanks for making me.

Despite everything, I turned out okay.

I will refrain from naming which persons were active participants in this conversation, and for some, this amount of anger was a bit exaggerated, but sometimes a bit of sarcasm helps one get through the day.

My ultimate point is this. NO ONE can stop you from reaching your dreams but you. YOU DO NOT NEED ANYONE to believe in you to reach your goals but yourself. People who appear to be confident and popular may have been shy and awkward as children. Successful and wealthy persons may not have come from money. Loving, nurturing parents may have been badly abused. That does not mean they cannot change their lives for the better. I have seen it many, many times. And the people who have come from unhappy situations to happy ones find more joy and happiness in what they have achieved than anyone else. Because there is no true joy without sadness. And they know that everything they have in life, they earned themselves. No one gave it to them, it is theirs. Because they had no help, it was even harder to obtain and they know it.

Many people walk into that graduation ceremony with no one there to be proud of them and they may feel very alone and scared. You may be in that situation. You may know someone like this. Tell them to read this. If this is you always remember: Be proud of yourself, walk tall. You are stronger than you think.

Healthcare and the Caribbean

I have been off on vacation at the beautiful island of St Lucia for a week and made my best attempt at not thinking about my job during that time. Everyone needs a break here and there and I am no exception to that rule.


I must say that as flawed as I find our health care system, it could be far worse. I looked through the phone book, which is a habit I have when I travel. It gives me a feel for the country and what life is like there. St Lucia had more physicians listed than attorneys, which is a positive sign, but they have precious few of either, and the physicians listed were almost exclusively listed as primary care providers. There are only two hospitals on the island, one public with only limited services, and one private with more extensive services, but obviously, at a cost. That hospital actually had listed two psychiatrists on staff. A tour guide said that at one time there was an effort to build a psychiatric hospital on the island, but the funding dried up and the project came to a halt. Many other specialized services appear to be fairly limited on the island of St Lucia, a situation that appears to be pretty much more the rule than the exception in Caribbean islands.


St Lucia, if anything, appeared to be economically more stable than other islands I have visited, although poverty is still quite rampant. Health insurance is provided for the elderly by the government, but not for younger persons and it is not generally provided by employers. A tour guide told us that if one wanted health insurance, it was the responsibility of the individual to buy it oneself. He did not say how much it cost but from the appearance of the homes on the island, it could be safely inferred that this was a luxury that not everyone could afford. It did not have the feel of desperation and utter hopelessness that one sees from the images in Haiti, even the ones prior to that tragic earthquake. I did not get the impression that most people were living "high on the hog" either and money was probably pretty tight.




In Caribbean islands I have visited, and Mexico also, people who work at resorts work six days a week, twelve hours a day or more and despite this, somehow always seem to have a positive attitude. It never seems to amaze me how they can maintain spending their lives catering to wealthy people who they know work many fewer hours, for much more money and with many more luxuries in their lives and still be so pleasant. Of course a good attitude gets tips, but these are all inclusive resorts and the guests are told tipping is included in the cost so employees do not expect to be tipped. That said, resort employees probably are much better paid than many of their peers. One would hope that most of the guests treat them with a fair degree of respect. Personally for myself, when I am on vacation I am in a pretty good mood and am not likely to be giving an employee a lot of trouble, but there are always outliers who do overindulge and can get pretty nasty.



It is inspiring to see such a positive attitude in people despite such harsh conditions. Things do tend to run more slowly and we learned on this vacation that five minutes in Caribbean time was a lot longer than American time, but considering how much people endured in their lives, it was easy to be forgiving if things did not show up as quickly as one would expect in the USA. And we could guarantee when it did show up, it would be delivered with a smile.



Caribbean drivers are the exception to the Caribbean time rule, and drive with an alacrity that makes even me nervous on curvy roads that are certain to cause motion sickness without a hefty dose of Dramamine for other nausea medicine of choice on board. Returning to the snail's pace I endure in a community heavily populated with retired persons stressed me more than the shock of the temperature drop. At least they appreciate a good thrill.



I do not feel bad for visiting the Caribbean islands although I know some do, feeling that we are exploiting a poor country. If they did not want us there, they would not treat us with such open arms. Tourism is a significant money generator for small islands that have few resources to exploit without destroying natural resources such as the rainforests, pristine beaches and mountains. Many areas have found a balance between allowing some development and too much, and improved their standard of living in the process. I hate to see this level of poverty so close to our own home and feel that people deserve better.

I wish them well.