Insight Matters
Summer, 2002

In the Trenches
by Brien W. Dyer, M.D., President

I thoroughly enjoy my job as a mental health and substance abuse crisis center medical director. Mostly seriously, I tell my residents on their emergency psychiatry rotation here that learning and practicing quality psychiatry is difficult, but not as difficult as simply arranging transportation to and from our office, helping the patient to obtain prescribed, life-saving medication and laboratory tests, or trying to find housing for a homeless family after all the shelters are full or have closed for the night. Oh, wait, is that a bruise I see on that three year old's cheek? I wonder if the county children's services bureau will give me a hart time taking this case. How long have you had that movement of your lips and tongue? You're pregnant? Your medication is making your menstrual cycle change, you are hemorrhaging? Your ob/gyn doctor wants to do a hysterectomy? You ran out of medication because you forgot your last appointment, could I just write you a quick prescription refill? Your husband is abusive and you haven't slept in three days. Doctor, could you please fill out these Social Security and a few other disability forms, it's all that's holding up my application, I've seen you twice now? No, I can't promise I will be safe it I'm not admitted to the hospital. What's that, how many patients are we behind? Yes, I did see that letter about productivity stating that an hour for an intake and 20-30 minutes for a medication check should be sufficient. You haven't eaten in how long? Tell me about your myasthenia gravis, diabetes, hypertension, and these twelve medications you are taking.

I'm sure that the above scenarios are not unfamiliar to many of us. They are part of the "biopsychosocialpoliticaleconomic" patient presentation that needs to be addressed to provide quality care. Now, take the above problem(s), presenting in a well-staffed urban mental health facility and move them to a rural county. I have been fortunate in my career to be in leadership positions in organizations (military, academic, and salaried hospital positions) that allowed me to do what I thought was best for my patients. Although I have done clinical level practice and have had moonlighting experience at state hospitals, I have had great support.

Presently, due to resignations of the only psychiatrist, nurse, and an administrative assistant at a small rural county mental health facility, I was asked to "fill-in" until a new psychiatrist was hired, an open-ended proposition at best. For two days a week I have been driving the 30 miles to the clinic and seeing patients, one after the other, with lunch being somewhat "iffy" and quick. These patients have many, if not all, of the above issues. The 8:30 a.m. to 5:00 p.m. schedule usually stretches to 6:00-8:00 p.m. When I roll home at 9:00 p.m. many nights, to explain to my spouse how necessary I was to these patients (certainly more important than my family), it was not a pretty sight or discussion. Most interesting to me, and the main reason I am writing this article, is the tremendous empathy I feel to those psychiatrists who have these experiences as an ongoing way of life. I quickly realized that I had a choice, between reading the thick old chart, doing a decent interview, helping the patients with the important issues mentioned above, writhing an informative, thorough progress not in the record, and getting behind and going home late each night, or just getting by with a few words with the patient and handing them a fast written prescription while wishing the patient good luck (but being on time). What a choice!

As I was explaining the neurochemistry of dissociative disorders to one patient, and of blackouts to another, a light bulb seemed to go on in their heads and they understood and appreciated an explanation of their distress. When psychiatric physicians are given enough time with patients to give quality services, let alone do psychotherapy, magic often happens in the room - people have a chance of getting better faster.

Organized medicine must continue to advocate for the fair rights/reimbursement of psychiatrists to practice quality medicine. The Ohio Psychiatric Association will continue to be involved, with your help, in this and other critical issues. Thank you, thank you, thank you for your dedicated and difficult efforts "in the trenches) that result in improved mental health and quality of life for our fellow citizens.

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