Kevin, MD, recently wrote a piece on “defensive medicine”, which he defined as

the deviation from sound medical practice to avoid the threat of malpractice litigation…. This can range from “positive” defensive medicine, like ordering unnecessary tests, referring to consultants, or performing unneeded procedures; to “negative” defensive medicine, like avoiding high-risk patients or procedures.

I initially surmised that psychiatry is not as susceptible to litigation and thus, is not as prone to practicing defensive medicine.

Upon further reflection, however, this is untrue. There are many examples of defensive medicine in psychiatry; let’s consider the role of hospitalization in preventing suicide.

There is absolutely no evidence that hospitalizing people who are endorsing suicide actually prevents suicide, both in short- and long-term follow-up periods. No one will ever pursue this study because it is ethically unsound. To apply the “gold standard” of scientific evidence to this question, the study would have to gather a large group of people endorsing acute suicidality (what would this definition mean? suicidal ideation only? an actual attempt? acts of self-harm that are not intended to end life, such as cutting? some combination of the above? something else entirely?). Members of this population would be randomly assigned to either hospitalization or something else that is not hospitalization (sent home? follow up appointment the next day?). If the “something else that is not hospitalization” is a return to the community, that could possibly qualify as “placebo”, but the fact that someone presents to the mental health field with suicidality is an intervention in of itself. And there is no way to “blind” this study: everyone will know who is hospitalized and who is not.

Further complications of this question include the context of the suicidality: Should diagnoses be considered, or should the focus be on suicidality only, regardless of “cause”? (For example, the person who is intoxicated with alcohol and is endorsing suicide is not the same as the person who is psychotic and is endorsing suicide in an attempt to “beat the aliens to it”.) Is there a difference between the individual who is enrolled in mental health services and followed the instructions of his provider to seek psychiatric help, and the individual who has never interacted with the mental health system and was literally pulled off of the bridge by firemen? Do we take into account the person who has been hospitalized over twenty times for suicidal ideation or attempts, versus the person who has never thought about it at all in the past?

It’s complicated.

In fact, there is a paper that suggests that the highest risk of completed suicide occurs during the first week following admission to and the first week following discharge from the hospital. The data from the paper also suggests that many other factors affect the suicide risk (shorter hospitalization lengths increase risk; mood disorders affect the risk the greatest; women who have been admitted in the past have a higher risk; etc.).

However, while this paper provides information, we cannot draw many firm conclusions from it (i.e. hospitalization causes suicide). First of all, the data from the paper came from Denmark (the country maintains a national population registry)—can we apply Danish information to Americans? the British? Australians? Secondly, we don’t know what the suicide risk is for people who are not hospitalized; that is, although the rates for suicide around the time of psychiatric hospitalization are at their highest, would the rate be significantly higher if people weren’t hospitalized at all? We can estimate how many people kill themselves, but we don’t know for sure—the health care system only sees those people who (1) failed in their attempts (or were otherwise “caught in the act”—pulled off of the bridge, had the gun yanked out of their hands, etc.) and (2) admit to thinking about it and are presumably ambivalent about suicide.

We never hear from or see the people who successfully kill themselves.

How does this relate to defensive medicine? Some psychiatrists routinely hospitalize patients (through coercion, either with or without the “help” of friends, family, et al.) who endorse suicidality when “clinical suspicion is low” that the individual will actually commit the act. The belief is that if someone is in the hospital, the risk of suicide drops significantly—after all, the ward is locked, there is less access to means of killing oneself, and there are people (nursing staff) presumably monitoring the situation. There is also the sense that the psychiatrist, by admitting this person, is “doing something”, versus asking the patient to return for an outpatient follow-up appointment the next day, which seems more like “not doing much”. (This drive to “do something” is also what propels physicians to prescribe medications that are not necessarily indicated.)

Sometimes, hospitalizing patients is not the most therapeutic or appropriate approach (for example, for people who endorse chronic suicidality). However, to reduce risk and prevent litigation, the patient ends up in the hospital to prevent a potential malpractice lawsuit against the psychiatrist. Psychiatrists are human and humans cannot predict the future. Humans can, however, assess risk—and some people are more risk-averse than others.

(To be clear: Hospitalizing someone does not mitigate the suicide risk. Patients do kill themselves in the hospital.)

The lack of data in this issue, though, reminds me of the BMJ parachute paper:

As with many interventions intended to prevent ill health, the effectiveness of parachutes [to determine whether they are effective in preventing major trauma related to gravitational challenge] has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

When jumping out of an airplane, one uses a parachute out of common sense. Can the same be said of hospitalizing someone who is endorsing suicidality? Does evidence-based practice only complicate (and obfuscate) straight-forward issues?

I don’t know the answers to these questions. I hope that there comes a day, though, where doctors and patients trust each other more… and that doctors can comfortably focus their energies on their patients instead of on themselves.

I recently performed a physical exam on a man who had assaulted police officers, despite receiving instructions to refrain from doing so. They subsequently used a taser on him—twice—and then took him to the hospital for psychiatric evaluation. While conversing with him from the doorway of his room, I thought about this piece I originally wrote in April of 2006.

1. If possible, learn why the assault occurred. Did the patient feel cornered? Did s/he perceive the police as engaging in offensive maneuvers and thus reacted defensively? Did s/he believe that other people were trying to trying to steal his/her identity by staring into his/her eyes for exactly ten seconds? Inquire into the specifics of the assault prior to speaking with the patient. This information will help guide your interactions with him/her.

2. Introduce yourself to the patient and inform him/her that you shall be performing a physical exam. You may need to explain, in detail, what a “physical exam” is, as some patients may believe that this entails invasive maneuvers, while others do not realize that this means you will be touching the patient. Something succinct, such as “I will listen to your heart and lungs, push your belly, tap you with this hammer”, usually suffices. (NB: Some people may take offense to the word “belly”, as that may insinuate that their torsos are of larger mass than you deem appropriate. Choose your words wisely.)

3. Observe the patient’s reaction to your announcement. Should s/he immediately threaten to hit, bite, spit at, or kill you in a loud voice while giving you The Stare of Death, it would be wise to defer the exam. Your personal safety is important. If, on the other hand, the patient accepts your announcement—even with some suspicion or trepidation—you may proceed carefully.

4. Transparency will work in your favor. The following suggestions apply to any type of patient, assaultive or not: Tell him/her exactly what you are going to do before you do it. Inform him/her that you will be placing your left hand on top of his/her head while you shine a light into his/her eyes to look at his/her pupils before you actually do it. Tell him/her that your hands are cold before you palpate his/her neck for lymph nodes. Tell her that you will be placing your stethoscope near/around her left breast. Patients are people and all people like to be informed.

If, at any point during the exam, you begin to feel unsafe for whatever reason, abort your exam and step away from the patient. (Realize that you are indeed vulnerable at certain points during the exam. For example, your patient could feasibly bludgeon you with the bell/diaphragm of your stethoscope. Those things hurt when they smack against your head. (Another story for another time.) Alternatively, your patient could wrap the tubing of your stethoscope around your neck and suffocate you while you are slipping the earbuds into your ears. I’m just sayin’.) Your personal safety is important.

5. If you are unsure if your patient is becoming angry or agitated, ask. You will be modeling effective communication skills and developing rapport with the patient. For example, should the patient loudly balk when you shine your penlight into his/her eyes, remarking, “That f@#$ing bothers me—why do you gotta do that?,” it is appropriate to say, “I understand that this may be uncomfortable for you, but I am looking at the size of your pupils. Are you getting angry with me?” Should the patient state that s/he is not angry with you, it is helpful to say, “Okay; thanks for letting me know. Please tell me if you are getting angry or if I am pissing you off (and “pissing you off” is an acceptable phrase to use); that’s the last thing I want to do right now.” Such a statement not only communicates your true intention (because, really, the last thing you want to do is piss off someone who had assaulted someone earlier), but also lets the patient know that you care about their mental and physical welfare. People generally like that.

If, however, the patient says that s/he is getting angry with you, it is helpful to say, “What can I do to make this more comfortable for you?” Again, a physical exam ought to be a collaborative effort—you cannot effectively gather useful information if you and your patient are fighting each other. Should the patient remark that if you got the f@#$ away from him/her, that would make it more comfortable, then get the f@#$ away from him/her. Repetition is good: Your personal safety is important.

6. Either during or at the conclusion of your exam, inform the patient of your findings and offer a succinct summary of your assessment. If the exam was normal, tell him/her that it was normal. If you heard a three out of six, crescendo-decrescendo systolic murmur that was loudest at the left upper sternal border, tell him/her that you heard a heart murmur that may warrant further investigation. Should you say nothing to the patient, s/he will wonder what pathologies are brewing within his/her body.

7. Ask the patient is s/he has any questions. This again suggests to the patient that you care about his/her concerns, thus building rapport (and reduces the chance that s/he will pluck the tomahawk reflex hammer from your hands and smack you repeatedly with it).

8. Thank the patient for his/her cooperation. Because s/he did. This is also how you treat a fellow human being with dignity. Often, these patients who have assaulted other people are not treated with dignity (because of their assault history); this can cause feelings of shame and worthlessness (even if you only sense a veneer of grandiosity). Your humility and civility may confer a more positive impact on the patient than you realize—and will again greatly reduce the likelihood that you shall be hit.

I was recently privy to an animated discussion amongst a group of boys:

• “If Superman and The Incredible Hulk got into a fight, who would win?”
• “How about Godzilla versus King Kong?”
• “Wolverine against Batman?”

Girls don’t have these types of discussions. I watched the debates unfold with interest… even when they derailed into ad hominem attacks:

• “You’re stupid!”
• “No, you’re stupid!”

(Where “stupid” is pronounced “steeew-pid”.)

I shall now apply the “who would win” question to selected state symbols of California and Washington.

California Quail (CA, obviously) versus Willow Goldfinch (WA). The quail is not only larger than the goldfinch, but it also can reside in more harsh environments. By sheer size alone, the quail would likely win. The goldfinch, however, may be able to fly more quickly (and frenetically) than the quail, thus escaping what would seem to be a certain pummeling. I still believe that the California quail has the advantage here.

Orca (WA) versus Grizzly Bear (CA). Technically, Washington doesn’t have a state animal, but it curiously has a state mammal. Since the California state animal is a mammal, I figured that pitting the two against each other is fair. The orca (killer whale) clearly has size and strength advantages over the grizzly bear and orcas are rumored to eat polar bears (though this apparently does not occur with high frequency). Orcas also travel at higher speeds than grizzly bears. However, orcas don’t do well on land, while grizzly bears can swim. Thus, the grizzly bear perhaps has greater adaptability to its environment—all it has to do is lure the orca onto land (though this still does not guarantee victory for the bear; orcas are huge). Should the grizzly bear end up in the water, though, it will no longer be a bear: it will become toast. Advantage: orca.

Columbian Mammoth (WA) versus Saber-Toothed Cat (CA). Both states feature fossils that have captured the imaginations of generations of children. The Columbian mammoth was the ancestor to elephants and their diets consisted primarily of grasses and other vegetation. Like many Seattle-ites, they were the organic, vegetarian types. The saber-toothed cat was definitely a carnivore and ate antelopes, horses, and other hoofed animals during the Ice Age. Thus, I imagine that a group of cats could take down a mammoth, if they weren’t trampled to death in the process. I don’t know how fast the cats could run, but I imagine that the mammoths were not speedy types. I somehow doubt that it would be a clean fight, but I think the saber-toothed cats would win.

Petrified Wood (WA) versus Benitoite (CA). I had never considered petrified wood to be a gemstone and I had never heard of benitoite. Petrified wood forms when silica (from lava) replaces the wood fibers of trees under pressure and over a long period of time. The original wood maintains its physical appearance, but its constitution is vastly different. Benitoite is apparently a rare gem that has thus far only been found in the waters of the San Benito River (hence its name). It sounds like it is a hard substance, as benitoite also has the moniker of “blue diamond”. The rarity, apparent hardness, and gemstone credibility of the benitoite suggests that it could easily defeat petrified wood.

Square Dancing (WA) versus West Coast Swing Dancing (CA). Square dancing is a dance that features call-outs (the caller tells the dancers what moves to do while the music is playing) and is thus highly structured and cooperative. If I recall correctly, partners are exchanged frequently, thus permitting all dancers to dance with everyone else. It is one of the more social of the social dances. West Coast swing is related to East Coast swing, the jitterbug, and lindy hop; it also utilizes more of the “slot” formation (both dancers travel back and forth on the floor as if in a slot). It is not a called dance and thus, the lead generates the structure of the dance. There is thus less uniformity. Partners generally dance with each other for the entire length of the dance. I am obviously partial to West Coast swing (due to my fondness for lindy hop), but I do think that West Coast swing has the advantage here: There are more opportunities for creativity and conflict in West Coast swing; the fact that a caller calls out the steps in square dancing suggests that it is more reactive than proactive. (As if any of this is really supposed to make sense.) For what it is worth, however, the state folk dance of California is square dancing and therefore, conflict is averted.

Green and Gold (WA) versus Blue and Gold (CA). Washington’s green represents the evergreen forests that carpet this beautiful state. California’s blue represents the endless skies that stretch as far as the eye can see (unless you live in Southern California, in which case the smog blunts the view). California’s gold represents the gold that glittered in the eyes of the miners during the gold rush; I have no idea what it represents in Washington (possibly the same thing). The color blue is associated with water, melancholy, honesty, and tradition. The color green is associated with the environment, jealousy, growth, and sickness (think cartoons). Blue is present in bruises and green is present before the veins split open from injury. By personal preference alone, blue has the advantage.

The dorkiness ends here.