Post-notices, any interesting patients are discussed and requests are made for additions to waiting lists for inpatient and day clinic or group therapy. Patients have to satisfy strictish criteria for admission to each; we're underbedded and oversubscribed as it is. Today's list started out quite normally, although saying that makes me realise how skewed "normal" becomes when you work primarily with inpatients: an asylum seeker who'd been brutally gang-raped and beaten in her home country and again on the journey here and is severely traumatised, not to mention physically damaged, as a result (public insurance; 6-8 weeks till admission time, intensive therapy till then because we can't empty the beds any faster); a couple of severe somatoform disorder patients, one of whom is convinced that her lymph nodes are rotting away; one psychooncology patient who needs to be monitored. Normal, normal, normal. Stomachs rumbling, surreptitious bites of sandwiches being taken, we all want to get out of the stuffy meeting room and go to lunch or back to work or just outside where it doesn't smell like forty pairs of feet.
Then someone starts off with, I know this patient comes from a bit far outside our area... and the atmosphere changes instantly. People tense, sandwiches slide back into bags, those of us slumped down in our chairs make the effort and lean forwards. If there's a patient coming in from miles out, especially from the direction named where there is a much bigger nicer facility, there's a reason for that patient to be travelling to us and we probably don't want to hear it. One therapist has a paedophile patient who travels about 40 minutes each way for his appointments because he needs to feel anonymous. Most of us don't know what he looks like and regard everyone coming out of that office with vague, hopefully-concealed suspicion. (And why, since he clearly isn't interested in us adults? The mind is a strange thing). Today's patient is different. He's not able to be treated at the much-bigger facility closer to him for a very good reason. He works there. He's a psychiatrist suffering severe burnout, and he's self-aware enough to have requested hospitalisation.
Nobody likes this. We all know that it's a risk in the profession. How could we not, given that they tell us about it obsessively, and that people offer us cocktail-party statistics about how psychiatrists are more likely than any other professional grouping to commit suicide? (N.B. If you know you're talking to a psychiatrist or someone who works in mental health in a social setting, don't talk about it. We're aware, and most of us think it's like telling a morbidly obese person how fat people are more likely to die of illnesses related to being fat: not cool.) His history's fairly uninteresting, as it goes. If he were a plumber or an A&E medic no one would think twice about recommending inpatient care asap, waiting list always permitting, and we'd all be free to go outside. This guy strikes at the core fear of everyone in the room, and nobody wants to treat him in case he's contagious. Nobody really thinks it's contagious, but it still feels a bit like walking through a thunderstorm with someone who's been hit by lightning multiple times. What if it misses and gets you the next time?
Debate is furious. The inpatient team claims that he doesn't need inpatient care and can manage with the dayclinic. The dayclinic therapists strenuously object and insist that he is sick enough to be an inpatient. Inpatient therapists counter with the perpetual bed problem: there's not one, and he needs urgent care. This is normally a killing blow and is reserved for emergencies, but the referring therapist spikes their guns: not only would he be triaged high up the list, but he has private insurance. Inpatient team are on the ropes, flailing for any excuse not to have to take this patient, but a compromise is reached: daily monitoring for 4-6 weeks and then reassessment.
Tensions ease. Everyone starts looking outside and gathering their possessions, only to be recalled by the start of the last patient history being declaimed above the noise of rattling chairs. This one's a student with a relatively minor stress-related ED, but she's originally from $other town and has the same surname as a rather eminent professor from $other town. The departmental head, who knows $eminent professor, takes her file and checks the biographical information. His shoulders droop a little under the weight of knowledge that only he could have confirmed and now we all know to be true. This is the daughter of $eminent professor, and if even the smallest mistake is made careers will be ruined on the back of it. He does everyone a favour and forestalls the debate: this patient goes to the dayclinic, and he will see her weekly as well.
We're subdued as we leave, although the normal chasing down of necessary people from other buildings is still going on. We're all thinking about how easy it is that a career can be ruined by taking the wrong patient. And it can happen in different ways. A patient who's too clever can induce burnout simply by becoming an all-encompassing part of your thoughts or by wilfully refusing to get better and causing you to doubt yourself. There are therapists who specialise in dealing with very smart patients. They tend to be vigorously eccentric, incredibly intelligent themselves and benevolently unscrupulous. They're also almost immune from burnout because the process is a game: they know the patient's trying to outwit them so they're responding in kind. Psychiatry as chess match. Or a patient can be too important, or related to someone who's too important, and a mistake will cause future cocktail-party or conference-break conversation: Oh, you're working in $city? My daughter had therapy there with Dr $ruined; it didn't go so well. Even people who know better tend not to blame the patients. Mostly, though, what's in our thoughts as we leave is how much of a relief it is to be trapped in those stuffy rooms listening to patient histories and fighting not to be overloaded with patients right as the summer is starting. As long as we're sweating together and dodging extra work, we're not on the far side of the equation, and we're not the ones being debated and dodged and passed like a buck. Because it can easily happen, and it does, and we don't know who's next.
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