During my psychiatric residency, I had the good fortune to train with a number of public and administrative psychiatrists. These individuals focused their attention on the care of the severely ill and the underserved and understood the systems of care that exist to provide this care. They also taught me the problems within the system and how it often creates more problems for the patients than it solves.
My story begins with the legend of the “oatmeal law.” As told to me, an elderly patient choked to death while eating oatmeal at a state hospital for the mentally ill. A blue-ribbon panel of experts came together to review the particulars of this case. The woman, who was in her 80s, was receiving a very high dose of Thorazine. She had no teeth. She was drowsy much of the day. The unit itself was very hot, and she may not have adequately hydrated. In short, there were many reasons for this unfortunate event. In the end, the blue-ribbon panel decided to ban oatmeal from the entire system.
I have always thought that this tale was true, perhaps because I have seen the system create changes that fail to address or even study the problem adequately. Over my 35 years in various administrative positions, I have seen many such laws come into being. In modern practice, the major changes have taken the form of new checklists, the so-called “zero” initiatives, and increasing regulatory oversight.
When there is a poor outcome, we look to create a new checklist or form. There are no poor outcomes in psychiatry, so every event is considered preventable, and a new form is seen as the best way to prevent it. I look at the “zero suicide” initiative and the influx of scales, forms, policies, regulations, and such. Nevertheless, in the end, nationally our rates of suicide are increasing. In fact, the only thing that has served to slow this down has been COVID, and we thought that it would be the opposite. Actually, those of us who have not read Durkheim thought that the rates would go up.
The regulatory push to make pain the fifth vital sign opened the nation to a destructive opioid epidemic. Although most leaders in behavioral health support the zero restraint initiative, we have also noted a steady increase in violence in the various psychiatric facilities with both staff and patient injury.
The list is endless, but there is no doubt that improvement in the way we care for patients is required, and it should be ongoing. I believe that it is essential that clinicians begin to take the lead in responding to these issues. I believe that we need to put front-line clinicians into the various leadership posts within the system. Health care should not be seen as a business. We provide healing and support, and we need to be led by those that provide this care.
Constantine Ioannou is a psychiatrist.
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