One day of a psychiatrist at a geriatric adult home

A sample agenda as the consulting psychiatrist at a geriatric adult home:

8:20am. Arrive at the concrete building. Wave through the locked glass door at the woman sitting behind the desk. She pushes a button and the door buzzes. Pull the door open. Say good morning. She never sounds cheerful when she replies, “Good morning.”

Because there is no open stair access, take the elevator up one floor. It travels slowly. The doors slide open on the second floor with the speed of a clam.

8:25am. Walk past the dining room. Many of the residents are eating breakfast. Silverware clinks against plates. Few people speak to each other. Some people make eye contact and nod hello. Some stare.

8:30am. Walk into the main office and into the recreational supply room. Sit down at the old desk and log into the computer. Stand up and arrange two chairs so that they are facing each other at about a 45-degree angle. During the summer, turn on the window air conditioner. In the winter, keep a sweater on.

Review the daily schedule and skim notes from the previous patient visits. Look over any notes from the consulting primary care physician. He’s an infectious disease doctor. He’s kind and intelligent. Make notes about what to discuss with each patient.

9:00am. First patient arrives. He doesn’t like to take psychiatric medication, but, for unclear reasons, continues to do so. As usual, he plans to walk about sixty blocks for exercise, but only along the major streets and avenues so that the government agents won’t try to kill him. He decides to wear a red necktie today to communicate to the agents that he knows they are monitoring him.

Scribble notes for the documentation later and schedule a follow-up appointment as needed. This happens after each meeting with a patient.

9:30am. Second patient arrives. Staff called for an ambulance two nights ago because he was disoriented and wearing pants on his head. He had bought three bottles of cough syrup from the bodega and drank them in one sitting. The emergency room released him and told him to stop drinking cough syrup. He bought three 24-ounce cans of beer this morning. He has only drank one so far. He doesn’t think there is a problem.

10:00am. Third patient hasn’t arrived.

10:05am. Third patient still hasn’t arrived.

10:06am. Call the front desk. The Woman Who Never Sounds Cheerful confirms that the third patient is in the building.

10:07am. Climb up two flights of stairs. Pass an elderly man who is slowly walking down the stairs, one arm holding the railing, the other an aluminum cane.

10:08am. Knock on the door of the Third Patient’s apartment. No response after 10 seconds. Knock again.

10:09am. Third patient answers the door. She forgot the appointment. Her memory is failing her. She points at a chair. She sits on her bed, the linens neatly folded. She plans to go to the adult day program today. Her dentures bother her, but she’s due for a size adjustment next week. She shows you the magazine pages she has taped to the wall: Whitney Houston, Michelle Obama, and Ella Fitzgerald.

10:27am. Return to the recreational supply room. Passed the fourth patient on the way back in.

10:29am. Fourth patient wants a tranquilizer, the kind that can induce mild intoxication. He talks about dirty liberals withholding medications from him. He hasn’t showered in about two weeks and wishes people would stop asking him about this. He doesn’t think he needs to clean his room, but rats have been nibbling at the leftovers he leaves by the bed. He doesn’t like that.

11:00am. Fifth patient just got back from a computer class. She is attending a talk this afternoon at the community center and plans to enroll in swim classes. On lower doses of medication, she smashes all of the mirrors in her apartment because Satan tries to kill her through the mirrors. She never talks about medication.

11:30am. Meet with the social work staff. Discuss possible new referrals. Also discuss patients who may benefit from visits in their apartments, as they may not be able to come to the office directly. Provide consultation on difficult interactions between staff and patients, and amongst the residents themselves. Talk about the weather, cookies, and news.

12:15pm. Lunch.

12:35pm. Begin writing clinical notes. Call a hospital to ask for an update about a patient. Review client list for the afternoon.

1:00pm. Sixth patient says he hates doctors. The primary care doctor won’t give him more pain medications, the psychiatrist probably thinks he’s crazy when he’s not, and the dermatologist doesn’t listen to him. For someone who hates doctors, he is always early to his appointments, has never missed a visit, and has to be assertively walked out of the room.

1:30pm. Seventh patient hasn’t arrived.

1:35pm. Seventh patient still hasn’t arrived.

1:36pm. Social worker thinks that the seventh patient is in his apartment.

1:37pm. Climb up three flights of stairs. Knock on patient’s door. He says, “Come in.”

1:38pm. Seventh patient is sitting in a chair. An open box of cereal and a nearly empty two-liter bottle of soda is on his nightstand. He hasn’t left his apartment in three days, even for meals. He hasn’t taken a shower in five days.

“The food is my body,” he says. Efforts to challenge this belief are unsuccessful.

“I don’t want to eat my body.”

He has been accepting antipsychotic medication over the past week. He doesn’t object to a higher dose of the medication. He learns that the dose will increase tonight and that staff will knock on his door before each meal to encourage him to come downstairs to eat.

1:55pm. Tell the social worker about plans about the last patient. If his condition worsens or he stops eating completely, he should go to the hospital for possible admission.

2:00pm. Eighth patient arrives. She hasn’t smoked any cigarettes in 12 days! She also, as ordered, stopped taking the antipsychotic medication about three weeks ago. The medication was tapered off over four months. She occasionally talks to herself, but this does not distress her. She reports feeling more energy. She also has a medical appointment in three days; she appreciates the friendly reminder.

2:30pm. Ninth patient arrives. He and his girlfriend are going through difficulties. He doesn’t know how to handle the situation; he’s not sure if he still wants to date her. He realizes that he is only getting older and thinks that he probably won’t ever date anyone ever again. He wonders if this is all he will ever experience.

3:00pm. Tenth patient arrives. He just moved into the building; he was just in the hospital a few weeks ago. He’s taking a high dose of an antipsychotic medication; if he stops taking medication, he soon believes that he will develop STDs from the people around him. This causes him to scream at people and throw things at them. He used to play the trombone and says that he makes a tasty lasagna. He hasn’t drank alcohol in twenty years. He’s glad to be out of the hospital and wonders if the building serves good food.

4:00pm. The eleventh patient won’t remember her appointment, so the meeting occurs at her apartment. The only furniture in her room is her bed, though there are no linens on it. The unfolded cardboard box is on the floor. That is where she has slept for the past five years. She is losing her sight, but she still applies lipstick every morning. She thinks the bricks in the building contain body parts of aliens, so she doesn’t want anything to touch the walls. She doesn’t want to take any medications, but she’s willing to attend appointments in the future.

4:30pm. Close the door to the supply room. Return phone call and speak to the hospital psychiatrist about a shared patient. Call grandson of the man who isn’t eating to provide an update and to help coordinate care. Leave a message for the primary care doctor about the woman who has stopped smoking.

4:50pm. Type up notes from the day.

5:30pm. Log out of the computer and walk out of the office. People are eating dinner, but the man who thought he was eating his body is not present. Take the elevator downstairs, and walk past the front desk, now manned by a person who regularly smiles. No one on the busy avenue outside knows what happened in the building earlier in the day.

All patients described here are composites of people I have seen across time.

Maria Yang is a psychiatrist who blogs at In White Ink.

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  • DavidBehar

    Doctor. You spent nine hours. You saw nine patients. Please, explain how you make your living doing so little in so much time.

    • azmd

      Actually, to me it sounds like she did quite a lot. There are other ways to measure what one accomplishes besides number of patients cranked through in the course of a day.

      • DavidBehar

        Yes. Most of it is worthless make work, of no value to the public, paper work, meetings, a complete waste of time and training.

        • Anon

          Uh, she saw 11 patients.

          You might want to slow yourself down a bit. It helps to avoid simple errors and not being able to differentiate between simple things… like 9 versus 11.
          She also spent 20-30 minutes with each of her patients, which you think is a complete waste of time.
          I take it you rush through patients in order to chase as many almighty dollars as you can in order to pay off all your malpractice cases?

        • Rob Britt

          Paperwork is worthless? How can you track a patient’s progress without seeing history? Compassionate care means listening to patients and that does take some time. 20 minute visit once a week seems pretty quick to me.

          • DavidBehar

            There is no relation between the quality of make work paper work and patient outcomes. Communicating with other doctors about a patient does make a difference in preventing errors and enhancing outcomes.

            One should make one change per visit. If one makes two changes one will not know which one caused either the benefit or the side effect. How long does it take a mid career person to decide what change to make? Most will be changes in dosage, since the brain is a slow organ that hates change.

            If you take money in exchange for friendship and consolation, that is called another profession. It is part of the job to be upbeat, to instill hope, and to make the patient feel better they came, even to make the patient laugh a little. However, that is not the reason one is paid. A friend can do the same for free.

          • Cheryl Handy

            It didn’t sound to me like author was merely offering friendship/consolation. The elderly are a very real part of our healthcare system and, like middle aged or young patients, some of those elderly need psychiatric care.

            Traditional IM docs would see fewer patients if those docs had more respect for geriatric psychiatrists.

            I guess ObamaCare will take care of the elderly and let them die bc they lived long enough.

    • Dr Souz

      Quick – See as many people as you can! Everyone knows that well-being produced is directly proportional to the quantity of people who come in and out of your practice.


      • DavidBehar

        There is drastic shortage of psychiatrists, especially ones willing to embrace poverty to work in a nursing home. When you chit chat about trivialities, and waste your time, another very sick person will not be seen for a long time. So, it is irresponsible to just have long casual, but worthless conversations, especially with demented and psychotic people, who probably do not even understand your bs.

        • Suzi Q 38

          Doesn’t most of psychology and psychiatry involve the rather long, meaningful conversations? They are personal and at times casual in order to garner information that will contribute to positive change.

        • Cheryl Handy

          “Chatting” with patients evokes concerns and symptoms that would otherwise be unknown to the physician. Actually, “chatting” would be great for a IM doc to try. But, especially for the psychiatric population, docs must engage in (sometimes lengthy) conversations to gain trust and thereby learn how the patient’s brain is processing information.

          No wonder there is a shortage of psychiatrists. Where’s the respect?

          • DavidBehar

            The public, through their government officials, has devalued what you suggest. They are not paying for it, therefore they do not want it, and will not get it.

          • Cheryl Handy

            Yet another reason why the government doesn’t belong in the exam room with doc and patient. Likewise “the public.” Likewise insurance.

            Doctors can only serve one master. Doctors can only owe a fiduciary duty of care to one person or entity. That person or entity must be the patient. Period. It’s just that simple.

            The public and government have absolutely no business determining whether psychiatric care to elderly patients is worth the money. And shame on any doctor for thinking otherwise.

  • Kathleen Robertson

    The last line of the post makes my heart sink.

  • Suzi Q 38

    I don’t know how you can do it all.
    A day with you and your patients would be rough.

    • DavidBehar

      Sweetie, you are not coming for a friendship for money. You are coming for the internal medicine of the emotional and behavioral parts of the brain. Friendship for money is called prostitution, even if Platonic.

      • Suzi Q 38

        So true, Dr. Behar.

  • margo

    yes. I guess that’s one of the main points of the article is the obliviousness of it all. No one is aware or seems to be concerned with these problems outside of the walls of the nursing home except for the psychiatrist….

    • Cheryl Handy

      Many of us families care. Many of us change our entire lives to be with elderly parents so they are not alone.

    • Suzi Q 38

      We cared. My FIL had had multiple strokes and was a total lift.
      After 6 weeks of physical therapy at a nationally recognized neuro center, he came home to us, being able to feed himself and make transfers. We called in a nurse during the day, 3 days a week.
      the other 2 days were adult day care days. He went to the school by bus. The weekends and evenings were taken care of by us, his family.
      this continued for about 7 years. After that, we were ready to place him in a nursing home.
      We saw him everyday for at least 30 minutes each day.
      My husband stopped by 2-3 times I week, I did the same.
      When the children could drive they had to stop by once a week on either Saturday or Sunday. This way, he had a visitor everyday.

      We felt bad that we were too tired to care for him in our home.

      My point is that there are families that do care and make an effort.

      • Cheryl Handy

        Families do care. Many of us gladly make sacrifices to stay with our family members. We know that our presence often makes the physicians lives easier. We can keep patients calmer than “white coats.”

        G*d bless you Suzi @ 38. You are an Earth angel.

        • Suzi Q 38

          Thank you. It was difficult, but we managed.

  • StephenModesto

    ..I liked your post. I specifically appreciated your note that the daily `logged’ chronology is a reflection of composites. I am then reminded of the `composition’ of the later work of Goya. You are painting an impressionistic vision with words within the pathos life circumstances which are endemic. Cure is marginally probabilistic and treatment is palliative. Yes, these are the darker colors of Goya.

  • drg

    it’s not that

  • drg

    it’s not that one person does not care I meant society as a whole-

  • Katherine Levine

    I shared on Facebooks, but really wanted to put this on Pinterest but it had no pinnable images. Please think about adding some to your posts. Even you picture would do.

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