Monday, November 9, 2009

The Learning Curve

The Red Telephone

It was about 10.00 PM and I should have been thinking about getting ready for bed. Instead, I was on the phone with the psychiatric clinician in the ER, trying to convince him my patient needed hospitalization. Until earlier that afternoon, day treatment had been adequate -- going home at night, returning for therapy the next morning.
Lately, however, his depression was worsening, problems at home seemed more severe, and he had begun thinking of alternatives, as he put it.To make things worse, he had a gun at home and was reticent about having his wife lock it up for him -- not a good sign.

We talked about inpatient admission and I walked down to the ER with him to get the evaluation process started.
I spoke with the ER director, she agreed with my assessment, and at that point, technically speaking, the decision about hospitalization was out of my hands. I had a funny feeling, though, that gnawed at me all evening.

When faced with hospitalization, patients can experience what's called "flight into health," which means they suddenly feel less distressed and despite having been suicidal hours before, for example, they deny it completely. And, of course, this means they don't meet criteria for inpatient care. The problem is, once released, their "recovery" doesn't last and their behavior can become rapidly lethal.

So, I gave in to the feeling and got on the phone. Sure enough, my patient had a change of heart and the evaluator was contemplating a discharge. A few minutes into our conversation he reversed his thinking and the next morning my patient said he was glad we'd decided not to listen to him after all.

They say you shouldn't take your patients home with you -- metaphorically speaking -- and that's generally true. But if you're going to care about the people for whom you're responsible, sometimes it's going to happen. You'll wake up in the middle of the night, make a call, and go back to bed glad you did. It doesn't happen quite as often as one might think and eventually, experience (and the supportive advice of colleagues) teaches you how to set limits on yourself. Like everything else in medicine, there's a learning curve and all of us are students, no matter how much practice we've had.

(Image by Toni Blay via Flickr -- creative commons licensure)

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