As I am not working for any outpatient services for the next 3 months at least, it is time to indict the system that is Community Mental Health Clinics (CMHCs), and that they are irrevocably dysfunctional.
There are multiple reasons for this, but overall it has come to a combination of 4 major elements, those being (1)pervasive failed leadership on various levels in the country, then (2)the lingering effect of the economic crisis that was 2007-08, followed by (3)the passage and then disastrous effects from Obamacare, and finally (4)the ongoing expectation and demand of technology in the various facets across society. The Quad-fecta that led to the current chaos, discord, and lack of patience and realistic expectation for reasonable and fair care interventions.
Having been doing temp work for most of the past 6 years, I think I am a fair purveyor of opinion on this matter, and will break it down into three parts, in no particular order of who is to blame, as all play equally lame and inappropriate roles to the deterioration of CMHC efforts to help the public.
First, the role of the patients:
**more than 50% of patients are drug seeking these days, as primary interventions for treatment if not solely the only intervention. And not just for controlled or abusable meds, nope, this is about expecting a pill to fix an ill. “Therapy, I don’t need no stinkin’ therapy”. Better living thru chemistry, folks, and, it ain’t working out too well, is it?
**I really believe I see almost half the patients coming into CMHCs have Axis 2/ personality disorder stuff comorbidly at hand, and that is not going to respond to primary medication interventions. Mood lability is not always a primary mood disorder, and yet, do colleagues really problem solve this well?
**Polypharmacy of three or more psychotropic meds is prescribed in almost 2/3s of patients, who want it more than one could believe! And, this shotgun approach to treatment, while not solely the patients fault, is really both fascinating and repugnant to watch, with patients ready and willing to take even more pills until proven otherwise.
**Too many patients are on multiple controlled substance prescriptions, at least 10% are on benzodiazepines like Xanax or Klonopin along with stimulants like Adderall or Ritalin, and what is worse, they often come in on opiates and then complain of symptoms most likely due to opiate intoxication or withdraw and then demand the benzos or stimulants that are only for these side effect issues.
**with the growing number of disability claims, workman compensation, and Family Medical Leave requests, it is beyond annoying and inappropriate for these patients to think they can come in the first visit and expect to be declared unable to work, have permanent disability, and my favorite, have PTSD from their jobs if actively employed. Are you kidding me?! And do these people realize that not working for extended periods, if not ever again, is not going to be at least somewhat detrimental?? I can’t medicate structure and productivity…
**Finally, the high dosages and the growing number of multiple antipsychotic prescriptions for alleged psychotic, but equally for these “treatment resistant mood disordered patients”, well, where is the literature for this plan, but, why are the patients so willing to be experimented like this? And the use of these meds for insomnia alone, just not defensible as a treatment intervention…
Alright, we’ve covered the patients’ role to the growing chaos and discord in CMHCs, now, let’s look at the role of the clinical staff, mostly the therapists, who equally collude into this BS:
**First, my favorite from therapists, staff will schedule patients with whatever doctor has a free slot in his/her schedule for a patient, because, hey, all doctors do the same thing. NOT! My running joke is send a patient into a room to be assessed by three different psychiatrists and the patient will walk out with 4 different opinions! Hey, wake up call, docs favor different meds, diagnose from the hip often, and worst, don’t pay attention to when they can follow up with the patient, so this reinforces other psychiatrists have to see some other colleagues’ patients.
**Favorite 1A with therapists, they send patients to see a doctor for an urgent visit, often without telling the doctor first why the patient needs seen sooner, think we can medicate psychosocial issues creating these urgent needs/crises, and then the best part, sets up therapy follow up like it is routine. Think about this for a moment, we have to see the patient urgently for a med change, and the therapist is going to follow up in what, 3 or 4 weeks, sometimes even later?! And tell the patient a med change is going to fix their problems!?
**Believe it or not, there are some staff, not therapists most of the time, who have the gall to write up Rxs for the doctor to just sign off on and take responsibility for the Rx, without reviewing it at times???
**these next two are about physician colleagues, first the Non psychiatrists who play psychiatrist with complete disregard to standards of care for mental health care prescribing, who dump their screw ups on us in CMHCs with polypharmacy regimens that you wouldn’t even see a first year Psychiatry resident be clueless to offer. These PCPs/Family Docs/Nursing Practitioners/GYNs/other somatic providers have the gall to say in one breath, “we can write psych meds, but, you the psychiatrist, have no right to prescribe somatic medications, EVER!” Oh, and you gotta love the Benzo Rxs, stimulant quantities, and multiple Rxs for antidepressants, or antipsychotics, and one of my most recent disasters, Lithium without lab monitoring for over a year. Thank you for this? NO!!!
**the other thing that is just obscene is the growing number of Methadone or Suboxone providers who are not only tolerating, but encouraging the use of Benzos, even Xanax mind you, with these patients on prescribed opiate meds often for opiate addiction treatment!!! Umm, for readers who don’t know, it is contraindicated to give Benzos to addicts, especially the ones on Methadone, until proven otherwise, the agenda is to get high with the Xanax!!!
Well, cathartic or not, writing this post is exhausting, so I will address the third part to this tomorrow, Aug 7, per what administration and outside influences of insurance and Big Pharma are doing to CMHCs as well. Have a nice Saturday night, or hope your weekend was nice as you read here on or after August 8…
to finish up,
Outside influences from non clinical care entities, well, what is there to be said, other than these folks are about money, PR, and control. Not always in that order, but, what are administrators, Insurers, and Big Pharma really after at the end of the day? And why do clinicians allow it!?
**Why do doctors agree, in CMHCs mind you, not private practice settings where docs have more control, and desire as well, to agree to see 30 or more patients A DAY??? Do physicians forget that studies have shown when you see more than 20 patients a day that malpractice risks rise logarithmically? I guess not, because not only do colleagues agree to this, but, encourage it? And maybe more a physician factor than administration, why do docs ask patients to come back in 2 weeks time after a med trial is started? What is that message?! But, at the end of the day, CMHC administrators really demand that doctors see too many patients a day. And yes, I get the no show rate is still at least 15% or more, but, maybe some of those no shows are because patients don’t see the need to come back SO SOON!?
**I am now being asked to do evals in less than 45 minutes time. UN-ACCEPT-ABLE!!! You cannot assess a patient in 30 minutes and do a responsible write up and move on to the next patient. Anyone who tells you otherwise is either clueless, complicit in this herd mentality treatment process, or, I guess likes being sued! And think about it for a moment, how can a doctor assessing for mental health problems really get an effective sense of the patient while doing a full bio-psycho-social review and simultaneously absorb a mental status evaluation. NO ONE is that good to assess a person in 30 minutes, unless he/she as the clinician admits that rule outs are the primary diagnosis, not a set diagnosis in stone.
**More and more I am seeing CMHCs ask docs to write Rxs for patients between appts, and not for those who have legitimate reasons to be out of meds not due to the patient’s fault. I worked at a place that had me write Rxs for 30 or more patients A WEEK, asking for a month’s supply more often than not, because these patients either no showed, were given a supply of meds for a way less time period than they could be scheduled next, or just patients trying to get controlled subs and admin staff too lazy to realize this was inappropriate. And even if not the active prescribers’ fault for the cause, if you don’t document that you are just supplying meds until a realistic appt time can be kept, well, good luck defending that if the patient has a negative outcome.
**With the influx of more and more refugees, immigrants even with legal admission to this country, much less the illegal ones, the translation barrier with those who will NOT make an effort to learn even rudimentary English is becoming absurd. Do any of you know that we have to use these phone translation services more and more, and think about this for a moment again, the patients who are psychotic and paranoid, you think they are comfortable talking to a person who is not in the room? Who is telling the clinician what the patient is allegedly saying?? And why language barriers only add to confusion and distrust to further the usual non compliance causing the treatment issues in the first place more often than not???
**On to insurers, readers here know of my absolute disgust and anger with this growing authorization process denying the initial request for meds, often simply about cost, has nothing to do with medications not indicated for the diagnosis at hand. But, do you know that more and more they ask for clinical information and are acting as a Respondant Superior (again the definition if interested: https://en.wikipedia.org/wiki/Respondeat_superior )role, which incurs on the insurer a clinical responsibility if claiming their clinical assessment trumps the treating clinician’s judgment. So, if the treating doctor is stupid enough to just reflexively agree to what the insurer demands, and again the patient course goes south, who do you think is culpable? I make sure once this demand for clinical information is demanded, I write those words “Respondant Superior role” in my paperwork back to the insurer, which so far seems to freak them out and just authorize my Rx request. How much longer that works, well, I guess the courts will have a role in that, eh? Which has happened in two states, California and Texas as I last read. Oh, and I forgot, insurers also are now even more boldly are denying diagnostic impressions too…
**Finally, this is both administration and drug companies collusion at full throttle, what is this BS with drug lunches for entire clinics, front office staff included, just to further hound and harass doctors who aren’t interested in having reciprocity (again a definition: the practice of exchanging things with others for mutual benefit, especially privileges granted by one country or organization to another.) used against them from all angles? I have learned to just sign off on them, but don’t attend the lunches, and yet, didn’t the FDA or other bureaucratic mandates eliminate this process as just bribery and manipulation?? We can’t get pens anymore, but, $100 or more of food every couple of weeks is fine??? And back to the point at the beginning of this part, why are non clinicians involved in the actual rep talks???
I am sure there are other things I have missed, but this list of pervasive poor judgment calls by so many in the process is more than a start. I just don’t get why so many colleagues just go along with all of this. I know burn out well, one reason why I am not participating in any CMHC assignments for now, but, I watch the docs who are in these clinics for years, and just worry why they can’t be more proactive and do the right things! Advocacy and demand for standards of care can’t be just dismissed or passively ignored!! Patients not only deserve better, but, so does the profession as a whole!!!
Well, this post was cathartic, but, also a bit of a downer. I had to write it though, as I had to document what I am seeing in my travels, and even if just my opinion, to not speak out in some form, then I am just as culpable as the rest above!!!
Thank you for reading, hope people will opine in any fashion.
Yeah, it’s like praying to an empty sky at times…