Wednesday, December 19, 2012

We Live in a Crazy World

Please, please, I must beg your forgiveness before posting this.  Sometimes, I just wish the world made sense, and it doesn't.  I should get over it.  

There is the story of a psychiatrist in France who was criminally charged with murder because a patient left and then, 20 days later,  killed someone.  The psychiatrist was found guilty and I believe she paid damages.  I think ClinkShrink may write about this on Clinical Psychiatry News in the coming weeks, but for now, I just couldn't resist the sarcastic pull that overtook me when I saw this...the psychiatrist guilty for another person's murder, the horror of our gun laws, and the ridiculous new CPT codes we will all soon be using.  If you are touchy about satire, please don't read anymore.
 French psychiatrist jailed for patient who committed murder
Here's the  missing back story.  During the consultation from which the patient fled, the psychiatrist was trying to figure out whether the several sentences the patient said about his episode of syphillis constituted psychotherapy or whether they were related to the medical aspect of the patient's care.  Should she utter supportive words, and tell the patient he may not have infected all 50 women he'd slept with [psychotherapy, supportive in nature], or should she suggest further testing to rule out possible neurosyphillis [medical intervention]. Would it take long enough to discuss and therefore be 25.1 minutes, so over half of the session would be devoted to counseling, and if she arranged for transportation to bring the patient back for an LP next week, well there's the coordination of care, and the documentation could be punted.  Oh, but unfortunately the patient began to talk about his father -- how mean, uncaring, and critical he'd been which had lead him to seek solace in the warm sweet bodies of prostitutes and could this relate to his relationship with his emotionally distant mother? So now the possibility of time-based medical management was lost, and an add-on code for psychotherapy became imperative.  The patient rambled on.  The doctor suggested they look at other similar relationships, were his sisters cold?  His aunts?  What about that favorite neighbor, Ester?  Oh, gosh, the doctor had now gone to 51 minutes of psychotherapy, so close to that 53 minute threshold for a higher add-on code and so much more reimbursement, when the patient announced, "I've had awful diarrhea from the medication you've been giving me?"  The doctor could take it no more and tried to sway the patient to just 2 more minutes of "You must tell me more about your mother!" Angered at his indifference to her lack of concern about his bowel habits, the patient reached into her desk drawer and pulled out the psychiatrist's semi-automatic weapon, a bushmaster high velocity rifle she kept to fend off both deer and madmen. He ran from the room while the doctor tried to figure out, was this a 45 minute therapy session, or could she have missed a moment of reflection, a tiny little abreaction, something, anything, to get that 52 minutes of therapy to be 53 minutes of add-on psychotherapy.  In the meantime, the patient and the weapon had gotten far from the hospital, and the doctor  realized she had only 5 bullet points on the exam and oddly enough, the review of the pertinent psychiatric system looked identical to the mental status exam.  Ah! She could comment on gait and get one more bullet point: "Patient walked quickly, but steadily, away from my office, bursting into a run, with my bushmaster rifle."  She had enough bullet points on ROS, exam, and past medical, family, and social history to bill a 99213!
    The patient ran and ran, firing rounds of ammunition, all intended to hit tree branches and drop acorns from the sky.  It went well, with the trees raining down an unrelenting supply of acorns until the ammo ran out.  Frustrated, the patient grabbed an axe, hoping his blows might shake more acorns from the tree and keep up the deluge.  An 80 year-old-man, seeing the rifle on the ground picked it up to ask about whether it was obtained at a show or from a store, and if the syphillitic patient was legal and rightful owner, when the patient became agitated, screaming "F*ck the CPT codes, it was a 30 minute session and a 99212 and that bitch is upcoding," and with that he swung as hard as he could for the tree, hoping a few scant acorns still remained to flurry down and pelt his head, when the old man jumped in his way and instead of hitting the tree, the  patient decapitated the old gent.  If only that doc had kept her  guns locked and knew her CPT codes.


roblindeman said...

I thought this was hysterical. The story of the French Shrink, pathetic. Nice mixture of the sublime and the ridiculous.

Leah said...

lol, I'm predicting some interesting comments on this one.

(who is not touchy about satire, at least not today)

LM said...

Oh Dinah. The posts people get upset and offended about are the ones in which you unfortunately aren't being satirical.

Don't you get it?

jesse said...

Actually, the French decision may not be as crazy as it sounds on the surface. Reading several news articles about this, the patient had been under the care of the psychiatrist for four years and had recently been having increasingly severe outbursts of violence. I did not see what transpired in the twenty days since the patient fled the doctor's office. Did she report his elopement promptly? What action should she have taken?

In our country it would not surprise anyone if she lost a several million dollar lawsuit.

But this follows the verdict in Italy in which several scientists were convicted of not warning sufficiently of the impending earthquake in L'Aquila in the Abruzzo.

Maybe Europe is copying our American tendency to award huge punitive damages in civil actions.

What I'm worried about is the degree to which mental illness will be the scapegoat after the Connecticut tragedy (can you imagine having to report the identity of patients so they cannot buy guns?) rather than severely limiting the sale of guns themselves to everyone.

Anonymous said...

I love the satire! Thanks for the laugh.


PsychPracticeMD said...

This absolutely made my day! Thanks.

I'm just waiting around for someone to bring a suit against God for injuries sustained during a natural disaster.

Anonymous said...

Jesse said,

""What I'm worried about is the degree to which mental illness will be the scapegoat after the Connecticut tragedy (can you imagine having to report the identity of patients so they cannot buy guns?) rather than severely limiting the sale of guns themselves to everyone.""

Excellent points. I particularly like the fact that you mentioned we need to worry about limiting the sale of guns to everyone vs. reporting the identify of patients so they can't buy guns. If you are forced to do that, that will negate all the efforts to destigmity mental illness.

And I am sure your patients will love being in a criminal database that could possibly jeopardize god knows what such as employment prospects. It is supposed to be confidential you say? Yeah right.


roblindeman said...


You appear to suggest that the psychiatrist bears a legal responsibility to make a good faith effort to prevent his client from committing crimes. I don't know about you, man, but think this through to its logical conclusion and ask yourself if you want to live in this kind of world:

In order to make absolutely sure that none of our disturbed clients commits crimes, the safest thing to do, to prevent our own butts from being thrown in jail, is to prophylactically incarcerate all suspect clients.

This is paternalism of the absolute worst sort.

No thanks.

Joel Hassman, MD said...

Enjoy whatever humor this post intends, here is the sobering reality that politicians will force on psychiatry and mental health in general as usual knee jerk reactions to incidents that have much chaos and lack of clarity, but demand instantaneous resolution, so the politicians can keep their useless jobs:

enjoy it for light reading.

Joel Hassman, MD

Anonymous said...

If the media keep interviewing extremists like Torrey, the only patients who will be left seeing psychiatrists are those receiving involuntary treatment. NPR should be ashamed. Thanks to people like him the stigma and hatred around mental illness increases rapidly. He will no doubt be able to harness that hatred and get legislation passed that will take away more of our rights.

Why do so many people take him seriously? The database on his website is made up of newspaper articles that link violence and mental illness. Does he actually research each of these situations to see if there is more to the story or does he just automatically assume if the words mental illness appear in a newspaper, then that must be the cause? Fearmongering does not equal research, but it sure gets the public and media stirred up.

Actions speak louder than words. It's not enough to throw out a statement that most people with mental illness are not violent, when he appears every single time a high profile violent act occurs, and before any facts are known. It would be comical if it wasn't so scary how quickly his organization, TAC, linked the Connecticut tragedy with lack of forced outpatient treatment in Connecticut. Virtually nothing was known about the shooter when they posted this on their website, but hey lack of facts are no problem.

i was talking to my therapist yesterday, and i just feel really concerned about the direction this is headed. I do not want to end up losing more of my rights because of what this creep did, and it's making me seriously re-think returning to my psychiatrist. if being odd and introverted is going to be the new bar for forced treatment, then there's a whole lot of people who are going to be in deep trouble. Not agreeing to take a medication will equal anosognosia which will equal psychosis which will lead to use of force. No thanks.

Anonymous said...

eaTo the previous anonymous,

I call NPR, National Psychiatric Radio, because they refuse interview anybody other than whom they can consider to be solid mainstream folks, like Fuller Torrey. They refuse to interview folks like Robert Whitaker who has created a website, Mad In America, to get people to rethink psychiatric care to go beyond the meds or bust type of thinking that now predominates the field.

And for you psychiatrists who keep claiming that Whitaker is a radical zealot, he isn't. He also has alot of mental health professionals who blog on his site as an FYI including psychiatrists.


roblindeman said...

AA, I've heard Whitaker speak. He's anything but a zealot. I find him to be a serious, thorough journalist. Even his understanding of brain chemistry is pretty good for a layman.

Catastrophes like Sandy Hook (I can't stand when people misuse the word "tragedy") are always used by government to justify increasing the reach of their power. In this case, sadly and shamefully, Sandy Hook will likely tighten the grip of the Therapeutic State, with the agency of willing psychiatrists.

Dinah said...

Being odd and introverted will never be the bar for forced treatment, there are simply too many odd and introverted people (many of whom have never been mass murderers) and we don't have enough funds or resources to provide care to people who are obviously ill and dangerous.

Somehow this shooter has become the poster child for the failures of the mental health system, but we don't know anything about his encounters with the system. We do know that he was likely insured (he was under 26 and his father was employed) and that with alimony of almost $300,000 a year, his mother could pay for his care, so he really doesn't make a very good advertisement to the lack of access to care. His public school assigned him a psychologist. We've read he was odd, anxious, and quiet. We haven't read that he was ever violent, or that there was any reason to believe he was capable of such a thing. We also know that as psychiatrists, we are not particularly good at predicting violence. So far, we haven't read anything to lead us to believe that this shooting was the result of a failure of the mental health system, and most of what we've read about mom is that she cared about him and was a conscientious mom -- if he was obviously violent, wouldn't she have secured the weapons? What would mental health legislation target? Nothing we've seen says this particular person would have been captured by a system with involuntary outpatient treatment -- though systems are for people who have indicated that they are dangerous.
I read somewhere that he was an organic vegan. Why aren't we proposing anti-vegan legislation? And certainly, we should not be selling guns to vegans.

Anonymous said...

Thanks for your response, Dinah. I hope you are right and that legislators won't go off the deep end in making things more difficult for people diagnosed with mental illness. I'm definitely an introvert, but have never been at risk of hurting animals or humans, on medication or off medication. I just bought lalaloopsy dolls for an adorable 5 year old niece, but the media doesn't care about those stories.