I have spent years watching the development of quality programs. What began as a way to ensure patient safety has gradually given way to an independent group of individuals whose job it is to interpret regulations and monitor those interpretations. In the process, the clinical richness of medicine has been lost. Judgment, narrative, and context matter less than forms and metrics. The work has shifted away from the bedside and …

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Reflecting on a recent meeting about upcoming audits by regulatory agencies, I couldn’t help but notice a significant shift. As the lone male leader and the second eldest person present, surrounded by a dynamic group of younger women, I couldn’t deny the passage of time since I embarked on my journey in administrative and public psychiatry. Far from lamenting, I welcomed this change, recognizing its necessity and long-overdue arrival. Witnessing …

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It is a typical day on the inpatient unit. A patient is refusing medication, and I want to take her to court to compel her to take medication while her lawyer is arguing for her right to refuse.

Me: “She’s clearly psychotic. She has lost her family, and she has no place to live… all because of these delusions.”

Lawyer: “But is she behaving in a dangerous way?”

Me: “Being unable to survive …

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I walk onto the inpatient unit on a Monday morning. The feeling of discomfort begins to overwhelm me. Perhaps this was due to being forced back to inpatient, but I felt it had to do with changes in the process.

I started my training at a time when therapy was a central part of education. Understanding even the most psychotic patients was a key element of our field. I do not …

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I have been working with psychiatric patients for the better part of 30 years. During this time, I have worked in psychiatric emergency rooms, prison wards, substance abuse treatment centers and inpatient psychiatric units. I have been proud of the fact that, despite working in some dangerous areas, I have never been harmed by a patient. I have been threatened, swung at — but never injured. Once a patient decided …

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