All right. Hello. Welcome to our session. If you are here for anything other than when provider bias becomes lethal, you are in the wrong room. So that is your warning. We are going to get started here with quick introductions. I'm Kelly Klein. I am the chair of the session. I'm the medical director at the Vermont Department of Mental Health. And our other speakers today. Hello. I'm Rana Kisti. I am the medical director at Riverside Medical Center for Psychiatric Services. Hello. I'm Sahil Munjal. Can you hear me? I'm at Atrium Wake Forest Baptist. I'm the program director there for a residency program. And James Kimball, clinical professor of psychiatry at Atrium Health, adult inpatient medical director. Okay. So our first session here is The Woman Who Cried Wolf. I unfortunately have no relevant financial relationships to disclose. Our learning objectives for this session is going to be defining what instant countertransference is, identify patients at high risk for provider bias, and identify potential legal implications for high-risk discharges and strategies for mitigating risk for both patients and physicians. So our first case is a young woman. She's in her early 30s. She is divorced for quite some time. She got divorced in her mid-20s. She has no children. Something important to know though is that she did have a history of fostering children and she did have a desire to adopt. When she went through her divorce, she then lost a lot of her financial stability and was no longer able to adopt. And at that time, a child that was in her custody had to be put back into the foster care system. At the time that she started presenting to the system, she was living independently. She had a high level of education. She was working on her master's. In fact, she would come on to the inpatient units and have some of her work to do online. She was once employed and her employment was actually working as a manager at one of the local women's homeless shelters. She was then unemployed by the time she started presenting and she had dwindling social support. So as these presentations continued, initially she would come in with a friend or a family member or someone from her religious community. And as they continued, only the one friend remained. So her historical presentation, for the first six years, they were very scattered visits to the emergency department. She had depression. She had emergence of some cutting behaviors, but it was very minimal. She had one suicide attempt via a low-dose overdose. And then about four years, three years, three and a half years-ish before the ending of her case, which we'll see how that happens in a moment, she started to escalate. So she had nine emergency department visits and a new diagnosis of dissociative identity disorder. And then in year two, she had 41 emergency department visits. So a pretty huge escalation. In year three, she had 40-plus emergency department visits, but she also moved out of state. For her diagnosis of dissociative identity disorder, she actually physically relocated to a different state where they have an inpatient unit for that diagnosis specifically because she wanted more intense care. Unfortunately, when she moved there, they essentially rejected her after about a month, month and a half, and they would no longer admit her to their unit. So she ended up moving back. And in the final three days, she'd only been back for about two months at the time, and she had very few visits. But in the final three days, she had a lot of visits to the emergency department. Five total. One, there was no mental health intervention at all. So she was seen by the emergency physician and discharged. One visit was without psychiatric evaluation, and this was the last visit that she had. There was a consult placed. The psychiatry service said, we don't need to see her. We already saw her today. Discharge. So there were some changes, though, in her presentation that were very important. So as I introduced the case, she was fairly stable. She had an independent living situation. Now she was newly homeless. This was the first time in her life. She didn't have any medications. And as you might imagine from hearing this case, she's been on pretty much everything. But she was not on any medications when she came back. And she was no longer connected to services. So we have designated agencies in the state of Vermont where people will go and receive their services if they're in that area. And they did not accept her case back as of yet. So they were still working on re-accepting her. So when she came back to the emergency room, it was 36 hours after her discharge. She presented as unresponsive and vomiting after apparent ingestion of 1,000 tablets of 200 milligram ibuprofen. She was found in the homeless motel by one of the workers there. She was intubated very quickly. CT head was negative. No one knew for sure if she had taken the ibuprofen. She did, though. She was given charcoal approximately two hours after arrival, started on levophed. She was admitted to the MICU, went into renal failure, started on continuous renal replacement therapy, had progressive hypotension despite maximum pressors. And then her friend actually did come for end of life, and they did terminal extubation 24 hours after presentation. And this was pretty incredible because it was right in the midst of COVID. And her friend was still allowed to come to the ICU and go through the terminal extubation with her. So let's talk a little bit about what happened here. She had recurrent presentations. We all know them. We all get frustrated with them. We all feel like we know these people so well. She will never actually kill herself. After this patient passed away, that was all that was said around the consult room. She was not going to kill herself. This couldn't have been on purpose. There's empathy fatigue. She had a personality disorder. So this is just a personality disorder, which we all know is not an accurate statement because a lot of times people with personality disorder are at higher risk for actually killing themselves. Whether they mean to in that moment or not, the end result ends up being the same. And provider bias. There was nothing anyone could do to help her. Now Vermont is a particularly difficult state to provide very specific care in, in a lot of ways. We don't have dissociative identity disorder units. We don't have personality disorder units. And so if you're also in a resource poor area, it might be very frustrating to get these individuals that need this extra level of care. And that kind of bias is a little bit accentuated there because there was nothing we could do in our state to help that individual. When we had to hospitalize that person, they had to go out of state. And that was always quite a circus. So let's talk about instant countertransference. It's the instant spontaneous set of feelings that form towards patients, even in the shortest of interactions. So when we think about the emergency department, because that's where the setting is for this, we think about looking at the board and the chief complaint, pain, suicidal ideation, agitation, all of these things bring up feelings before we've even met the patient. And if any of you have read the book Blink, instant countertransference is a lot like the medical version of Blink. It's that instantaneous impression that we get of somebody the moment we walk in the door. So those at highest risk for this are people with personality disorders, high levels of suicidality, repetitive self-harm, and violent, hostile, demeaning, or threatening behavior. So back to this case, this individual had extremely intense self-harm, carved words into themselves, had cuts so deep that they had to go to the ICU for repair, actually had a saddle embolism before they moved out of state because they put themselves into a post-operative state with all of their cutting. And had a clot. So this person in particular, as you might see, had pretty much everything except was not violent, hostile, demeaning, or threatening, was very pleasant, actually. So some more risk factors, if we look at general risk factors, people that are homeless, there's a very high risk of instant bias towards them, poor social supports, poor finances, legal involvement, a lot of times as soon as that's found out that somebody has legal involvement there's a question of is this why they're here, multiple medical comorbidities, people start to question which one is real, are they real, race, gender. And then we look at the psychiatric risk factors, chronic psychotic illness. Is this person actually in an exacerbation or are they experiencing something else? Are they newly homeless? Do they need housing? Do they need food? Is that why they're here? Is there a secondary gain? Impulse control disorders, it's very difficult as providers to see these individuals as needing medical care when they're being harmful, especially in the emergency department or the medical setting. Borderline personality disorder creates a whole lot of countertransference, antisocial personality disorder, and those that self-injure. So the risk that's associated with that to the patient is minimizing patient risk level, going in and saying we already know this person, they're not high risk, they're not actually ever going to kill themselves. Premature discharge, not finishing the workup, not making sure we have a safe disposition in place, inappropriate level of care recommendations, they're not going to benefit, we've already been inpatient 50 times, they don't need it, lack of linkage to outpatient care or resources, and serious self-harm or violence, outcomes can be lethal. So when we're discharging someone like this, we also have to think of ourselves as the providers and the legal considerations behind this. What would a reasonable physician do in this same exact situation? So if I'm frustrated with the patient and I want to discharge them, I might need to pause for a second and think what would Dr. Kisti do? And he discharged the patient even though he's never met them before. If he looked at the same set of risk factors, what would he do? And if it's different, we might need to go back and look at our evaluation again. And then we also have to consider EMTALA. So who needs to evaluate the patient before they are discharged? In the case that I'm presenting, psychiatry declined the consult. I can tell you that CMS did not like that. If there is a specialist available and the consult is placed, they must provide the consultation in the emergency department because it's seen as a medical emergency. And the highest level available needs to do that evaluation. And so what kind of dispositions are considered to meet EMTALA requirements? They must be able to be discharged with reasonable certainty that their condition will not deteriorate. So let's talk about how to document and assess for that. A very important thing that was missing from this case in particular was assessing and documenting current suicide risk. Everything in the documentation for this patient was talking about the fact that they had very, very high chronic risk factors. And it was all over the chart that they were at high risk for killing themselves eventually. But in reality, we went through the fact that there were brand-new risk factors. And those were overlooked because it was the same person walking through the door. We want to document any protective factors if the patient is walking out the door. And the reason that treatment in an acute care setting is not indicated. So we run into this a lot with individuals that come in and say, I am suicidal, I'm going to kill myself. Is there actually an acute psychiatric process going on? Are they saying that they're going to kill themselves because of command auditory hallucinations or because they're undomiciled? Two very different situations. And we need to document specifically the presence or absence of those acute psychiatric processes. And all conversations around discharge. Did they participate in a meaningful way? If it's their third time in that day, did they say, F you, I'm not going to discuss this with you? Or did they sit down and have a reasonable discussion and say, I can't go because X, Y, Z? What are the options for disposition? Again, if we're not going to hospitalize somebody saying that, that this is not an option, because this person will not benefit from an inpatient level of care because of these reasons. Was the safety plan attempted, completed? Did we start it? Did they participate? And then last case scenario is to consult with another physician and document that consult. It can be a curbside. I might just call Dr. Kimball and say, what would you do in this situation? So how we avoid this trap. When we get back to the instant countertransference, people that walked into this patient's room were immediately annoyed. Very pleasant human, like I said before. Very pleasant, but annoyed because they'd already seen them three times that day. So sometimes we have to remove ourselves. The one where you walk away. Recognize that we're having feelings of anger, frustration. Remove yourself for a few minutes. See if you can re-evaluate and come back. The one where you follow standard of care. This is a particularly helpful one, I think. It's my favorite. It's where you remove that patient's name from your narrative, right. So if you're a resident, you're giving a presentation to an attending, you realize you're frustrated with this person, pretend it's a different name, a different human. Then tell the story about what's happening. And what plan would you give somebody else? That is probably going to be standard of care. And the most difficult one is the one where you realize you don't care. Like I said previously, there was so much talk when this individual passed away in the consult room. It would be shocking to hear this kind of talk where people said she was going to kill herself anyway. It was only a matter of time. There was nothing anyone could do. And some of that might be true. But at the same time, that shows that we lost a level of empathy. And feelings of apathy are definitely more difficult to face than, you know, being frustrated or angry. So it's easier to recognize than to recognize that maybe we just don't care at that point. But it's a big problem. So we need to get a second opinion. Whenever you recognize that in yourself, that you're just not caring about the situation, get a second opinion. What would somebody else do? And then talk to a mentor. Start asking the difficult question of why. All right. We're going to go through a very quick case. This is a patient well-known to the psychiatry service, presents to the emergency department for the second time in one day. Similar to their prior presentation, they're reporting suicidal ideation in the context of not having housing for the upcoming night and being fearful to sleep outside. I would rather kill myself than be killed by an animal in the middle of the night. Have you tried sleeping on a park bench? Okay. So turn to someone next to you, and we're going to go through some questions here. Let the person next to you know what your initial reaction is, or your initial feeling to hearing this presentation. Discuss. »» It can be a person behind you, in front of you, too. »» Okay. Is there anyone willing to share? Is there anyone willing to share their initial feeling? Raise your hand. Anyone? »» Otherwise, Dr. Klein is going to force one of you all to come and talk, so somebody better volunteer. »» Ah, we have someone. Thank you. What was your initial reaction or feeling? »» This isn't psychiatric. »» Yep. Excellent. Anything else? »» Welcome to America. So I just want to comment. We have seven emergency rooms and four inpatient units in the system that I'm in charge of. And part of them is in Camden, New Jersey, which is one of the poorest cities in the USA. And this is routine. And in fact, I would say this is not maladaptive coping either. And it's really almost, I applaud you for having this meeting, because this is the most problematic patient population, not just this presentation, but the previous one that we have in our system. And it's really hard for people to have compassion. You definitely get compassion burnout. I'll just say that. I applaud you. And again, we don't have enough social supports. And the emergency room is actually very accessible for most people. »» Yeah, it's safe. There's sandwiches. You know? It's not the worst coping skill. »» I don't know how much I'm going to negotiate. »» Here comes the argument, right? Okay. Can you identify any risks that this patient may have for a poor outcome in comparison to a person who's not known to the service? »» A guy that comes in very frequently, he came to see the resident the second time the same day, the same resident. And she was like, oh, it's going to, I was like, you got to go see him, because you just don't. »» Yep. »» You just don't know. »» Yeah. »» Who knows? »» Yeah. Very at risk for not finding out, not being curious, right? If someone's brand new to the service, especially, I don't know about other states, but in Vermont during COVID, we had a lot of individuals come from very far away in other states because of the shelter programs that we ran. And there was always a lot of curiosity for those patients. You're from Colorado. Do you know it's cold here? Are you sure you want to be undomiciled here? But there was a lot of time spent with those individuals versus people that we know. We just go through it quick. We already know them, discharge. And there might be something new going on. And this is one to talk amongst yourselves again. How can you mitigate risk both for the patient and yourself in this situation? Because providers are also at risk in these situations of missing something major. So chat amongst yourselves for a minute. Okay. Is any group willing to share their thoughts on mitigating risk in this situation? No one heard me yet. Okay. Is anyone willing to share? What can be done? This is a hard one, I think. But oftentimes, sometimes when you're fortunate, you can find actually a safe disposition for them, which can be challenging. But sometimes like our social workers will be able to find them a shelter. And then we'll ask them like, you know, now that we have housing for you, let's talk again about safety. Sometimes it has resolved and sometimes it hasn't. That's the ideal. Yeah. So trying, right? And documenting that we have tried. See if there is a safe disposition to send somebody to. Sometimes that's a big dream. That's not going to happen. But if we try, then we tried. And we documented. The other thing to do is try and identify other things that the patient may want or need that can be provided at the time. And that includes simple things like bus tickets, blankets, food. Yeah. Sometimes all the patient really needs is, you know, maybe a PRN of the medication they're supposed to be on. Or they may benefit from contacting somebody that they know who could be supportive or helpful. These are all things that people sometimes don't think of doing, meeting the patient halfway in their needs. Yeah. And that's a great technique to use. It's, you know, especially if someone is malingering. And instead of getting into that argument with them, finding some common ground, something you can agree on, some sort of alliance that you can build. Instead of just going back and forth with, you're not psychotic. We both know you're not psychotic. That's never going to get us anywhere. So instead of that, focusing on, but what do you need? We can't go inpatient. We can't admit you right now. But what can we do? What else would be helpful to you? Anyone else? All right. All right. So we are going to move on to our second session. Dr. Kisti? Thank you, everyone. Thanks for attending. I did not realize so many people would participate, and now I have to be on my best behavior. So fingers crossed. So hi. I'm Rana Kisti. I practice in rural Illinois in a very, very small community psychiatric hospital. And so if there are any community psychiatrists out here, you probably know that there are certain challenges, especially with people we call as frequent flyers. So I think this is one of our frequent flyer cases, and hopefully people will identify with this situation. So I do not have any financial disclosure. So what am I trying to actually talk to you all, right? We all talk about bias. Implicit bias. Explicit bias. Oh, my goodness. Dr. Kisti, you're going back to first aid when we were preparing for our complex and USMLE exams, where they asked us all about implicit and explicit bias. But how does this apply in real life? And I really wanted to talk about our implicit and explicit biases, number one. And number two, really recognize it. And number three, what can we do about it once we recognize it? So this was a case that presented to, that we were very, very, who was very well known to the psychiatry service. He was a white male in his late 50s, had a long past psychiatric history of MDD and generalized anxiety disorder. Also had a long history of substance use. And interestingly had been in remission for some of them, which was very helpful for him. But he also had a history of three prior suicide attempts, including drinking antifreeze and overdosing. I mean, very, very serious attempts. So these were not just, hey, you know what, I'm going to make one small superficial laceration on my arm. But these were very serious suicide attempts. And then he had tried and failed multiple psychotropic medications. As you all can see from the entire list, right, he's tried SSRIs, he's tried benzodiazepines, he's tried mood stabilizers. I mean, he, and this is definitely not the comprehensive list of medications that he's been on. This is all I could actually find documentation for, but he has definitely tried and failed a lot of psychotropic medications. Has had intensive inpatient as well as outpatient psychotherapy services. Again, like going on with his history, right, or the past year, primarily marijuana, but does have a history, past history of other substance use. And socially, interestingly, I mean, had decent social support. I mean, he lived with his wife of several years. I mean, he, she was very supportive. She herself struggled with some of her mental health issues, but was overall very, very, was one of his primary support systems. He did not have any children and no legal history. So if you just look at it, just from a primary social standpoint, pretty okay protective factors that he had. However, now look at that, right? Since 2016, all the way through 2022, he had at least 115 touch points, right? At least 115 touch points, meaning around at least 30 touch points with the psychiatry service every year on average, right? 30, meaning phone calls, office visits, inpatient psychiatric stays. That's a lot, right? 30 per year, meaning at least two, at least two to three a month. That's how intensive, I mean, he had access to services or at least touch points with the psychiatry service. He had a history of heavy alcohol use for several years, again, has been to substance abuse rehabilitation programs, both inpatient, outpatient, and has been in SMRFs. Does anybody know what a SMRF is? Anybody from Illinois here? I can see Dr. Azov here who's smiling, but SMRFs are, I don't know if they're unique to Illinois, but they're basically like residential treatment centers for primarily mentally ill. You go there, you primarily live there, and they provide you with a lot of services, including psychiatric services, case management. I mean, I think it's a very decent model to have, but he's been in multiple SMRFs. And so, like it says, these facilities help with adaptive functioning of patients with mental illness. They facilitate the recovery and really help them achieve a high level of independence, right? Whatever that independence looks like. 2021, right? After so many years of us knowing him, we were like, you know what? Let's get another neuropsychological evaluation, right? I mean, what are we missing here with this guy? Interestingly, IQ came out to be 62, right? Definitely declined from his estimated pre-morbid functioning, since he was well known. And if you see, he definitely had problems with memory storage. He had problems with visuospatial functioning. And really, he could not even, his word recall wasn't the best either. And the last point is kind of very sad. I mean, he didn't even benefit from reminders during the testing. So again, right? Executive dysfunction was very, very clear on neuropsychological testing, and he had significant difficulty and benefiting from feedback in order to guide his decision making. So he was constantly perseverative on things, even when responding. On further testing, right? There were concerns for, you know, problems with slowing in his left anterior temporal lobe and on the BDI and the BAI, there was very clear symptomatology for depressive and anxiety-related symptoms. Sorry, going back to that. So his profile was, again, look at that, right? Clinically elevated on somatic complaints, depression, hysteria, right? I mean, we all have those patients who come in saying, having somatic complaints, and our primary go to is, oh, this is just somatic. You know, why can't this be treated outpatient? And 2021, there was concern after neuropsychological testing for major neurocognitive disorder due to multiple etiologies, right? I mean, look at his history. He had a clear-cut history of chronic and severe alcohol abuse. So number one is this of vascular etiology, the major neurocognitive disorder. There were concerns that he might have had TIAs or stroke on neuroimaging that just went undiagnosed. And in 1981, he had a motor vehicle accident, and there was clear documentation of a traumatic brain injury. And at that point, neuropsychology recommended that he receive, you know, he would benefit from 24-hour supervision. His wife was appointed as his power of attorney. She was really very supportive and would help him with complex decision making. So at this point, we think, OK, we've surrounded him with good support systems. He's already plugged into our clinic, and hopefully things would be OK. And then look at all his inpatient hospitalizations, right? At least 10. So he had hospitalizations in 2015, 2016, sorry, 2017, multiple ones in 2017, 2018, and 2022. And look at all the things he did, right? 2017, in just half a gallon of antifreeze, right? Not just a tiny cap, right? Half a gallon of antifreeze, unknown amount of valium. 2018, he left the stove on. Good God. And look at what he did, right? Didn't just leave the stove on, but had unhooked the smoke detectors. This is a very, I mean, this was very intentional, right? This is very, very concerning. And in 2022, again presented for suicidal ideation. After we discharged him, he was admitted in 2022 after this for suicidal ideation. And after he was discharged, he presented again in about 19 to 20 days. Now, at this point, he presented to the emergency room via EMS because he ingested overdose on gabapentin, which also I think is like a miracle drug, right? Gabapentin we prescribe for basically everything. Alcohol, anxiety, mood stabilization, pain. Perfect. So my symptoms here get gabapentin. And so earlier that day, EMS was actually called to his home. It was called to his home by his wife and his neighbors for suicidal ideation. So interestingly, EMS, who has had many touch points with this patient over several years, goes to his home since they know him very well. And he says, no, I'm not suicidal. I don't know what they're talking about. And EMS actually even documented because they had no evidence that he was actually suicidal. They left. They left the scene for a person who they know really, really well, right, in a small community. They simply left and then they were called back again in a few hours. And at this time, he had made homicidal statements and had ingested his gabapentin when the police department actually showed up in front of his place. He started drinking again and for which he was in remission. And then wife again reports concerns like, you know what? This is not baseline. So he gets aggressive with the cops. He gets ketamine. I mean, he gets brought to the emergency room and actually ends up being admitted to the ICU. Right. He has fluids. I mean, in the emergency room, he is stabilized and then his symptoms worsen. He gets admitted to the ICU and he passes away. Right. For a person who was very, very well known to the psychiatric service, not just psychiatry service. Right. I mean, even EMS, even outpatient mental health providers in the community. Again, it's a very, very small town. And what did we miss? Look at that. Why did EMS not bring him to the emergency room the first time? That is the first question. Right. And look at her back. This is just behavioral. Right. I mean, he's just doing this for attention. He probably fought with his wife. Right. I mean, why do we need to do this? He'll calm down. We know him very well. Number two, patient is simply drunk. Right. I'm going to overshare a little bit. Right. I think Dr. Klein and Dr. Kim will probably know. Right. When I when I drink like I, I'm not a fun person to be around. Right. I mean, I'm not a happy, tipsy person. I will drunk call. I'll drunk text. I get really, really anxious. And then I will, you know, I almost get paranoid. You know what? The cops are going to arrest me for disorderly conduct and I'm going to be deported back to India. Right. I mean, so on the other hand, Dr. Azov right there, if she raises her hand to you all, she is so much fun. She is she is fun when she's tipsy, guys. Come on. So the point I'm making is the same substance has different effects on different people. Right. And so when we make this blanket statement that he was just drunk. OK, but just as there are people who are happy drunks, there are people who are anxious drunks and there are people who are sad drunks. Right. The same substance can have can have very, very different effects on different people. And we absolutely have to take that seriously. And we know him well, he is not going to hurt himself. Right. What Dr. Klein had presented. Same thing. Right. We have this automatically comes up. Right. We know him really well. He's not going to harm himself. Tons of biases. Right. Look at the list. Racial, ethnic, gender, socioeconomic, right. Explicit, implicit bias. Lots of biases that we have. But I'm not going to go over all of these. You guys will fall asleep. I don't want that. What can we do? What y'all think? Can we have a discussion for a couple of minutes and you guys can tell me what we can do? Look, look at each other or behind you and discuss what can we do to reduce our bias? Otherwise, Dr. Klein is going to come and nominate somebody to talk. Perfect. I need a volunteer. Hello. Anyone want to share their experience? Somebody come up to the microphone. I promise I won't bite. Well, if I'm lucky enough to recognize that I have bias, I generally try and step back and talk to somebody else who may know the patient. Absolutely. Yeah, I think that's that's a very valid point. Because if we know this patient really, really well, at that point, our biases immediately take over without us even recognizing it. So definitely talking to somebody who would probably be a third party. Take a look at it with fresh perspective. That would be really, really helpful. Three steps. Let's be aware of our implicit biases. Right. What is an implicit bias? Right. I am going to like say, are there any female psychiatrist providers in the room? Right. Ever been called a nurse? Right. Implicit bias. Right. Or let's say if I say if I even say the words kindergarten teacher, pretty sure in a lot of your minds, a female would probably pop up. Right. I never said a female kindergarten teacher. I just said a kindergarten teacher. Right. So implicit bias. And sometimes it's very, very hard to recognize. So we should be motivated to change ourselves. And choose to implement bias free behavior, which is really, really hard. So explicit bias. So explicit bias is, you know, often a self-reported it's within our conscious awareness, meaning overt racism. Right. That's an example of explicit bias versus implicit bias. Right. Was primarily outside our conscious control. When I said kindergarten teacher without even meet, even without people thinking. Right. What you probably conjured up was a female or it was a female person. Right. So it's out of our conscious control. I think the key is going to be to bring it into our conscious control. So we are aware of these implicit biases that we have. Again, implicit bias towards people with mental illness being bad or helpless. Primarily with EMS. In this situation, this was not psychiatry providers right in the hospital, but this was EMS. These are our first responders. When they respond to these crisis, I think they also we need to have significant training for implicit and explicit biases so that they are able to actually take a step back to validate the situation objectively and provide provide the help. And look at this study. Right. In 2010, Wall and Arasiko and actually found that many mental health professionals doubt the possibility of recovery. Right. So basically, most of us in this room really doubt that these people are going to recover. And the question is, what does recovery look like? And in our mind, a lot of times recovery looks like a normal, typical functioning adult. Again, the point is recovery looks very different to different people. And I think we really have to remind ourselves of that over and over again. So what are the strategies? Right. What can we do to reduce our implicit bias? Number one, be aware. Right. This is going to be the hardest part. Let's be aware of our own bias and redirect our response. And then stereotype replacement, meaning recognizing that our response is based on stereotype. Right. Kindergarten teacher, female. Right. How do we replace that stereotype and adjust our response? Counter stereotype imaging. Right. These are all big words, but imagining the individual as the opposite of the stereotype. Right. What would happen if we imagine that a kindergarten teacher is male? Right. That's basically what it says. Seeing the person as an individual rather than the stereotype, that would be very, very helpful. But the problem is we are all there's a dirt of psychiatrists in this country. We are all so overworked that it's hard. This is hard to provide individual care and our burnout is also very real. So, I mean, this takes a lot of practice. Perspective talking, putting yourself in other's shoes. I would like to think that we try to do this, but again, burnout is hard. Burnout is real in our profession, and I think this is very, very difficult. And partnership building, really reframing the interaction with the patient as you're collaborating with equals. So, strategies to reduce our implicit bias. Basically, have a basic understanding of cultures that your patients present from. I think it's easier to do that in a smaller community setting, where I think it's easier to get an understanding of the culture, but really having, even in big cities, right? Big hospitals really feed from a particular geographic zone, if not specific cultures, and I think that would be very helpful to know what cultures, what backgrounds are our patients coming from? Don't stereotype them. Point is to individuate them. Understand and know that sometimes there is going to be bias, and we are going to try our best to actually overcome it. Does anybody know what class standards are? Does anybody know? I would strongly recommend everybody go to the HHS.gov website, right? So, Health and Human Services website. They've actually published a national, culturally, and linguistically appropriate services standards, where they really talk about how do we recognize and utilize appropriate cultural and linguistically appropriate language in our treatment and care of patients. Do a teach-back, right? Really, talk to a patient. When you're educating them, have them repeat back what you just taught them, right? This is very, very helpful to help them, help us understand whether they actually understood what we said, especially when it comes to safety planning. And, of course, hopefully, practice evidence-based medicine. And so, before I move on, any questions? Oh, questions at the end? Oops. Promise I'm not drunk. There's no alcohol in this. All right. Now I'm gonna talk about a case that I'm positive that you have seen, though, that similar case many times in your career. And we'll kind of touch upon a lot of issues with counter-transference and bias that's already been talked about, and how that affects not only the patient, but you as a provider. Okay. So the learning objectives are, we'll discuss a high-utilizer patient who seeks hospitalization medications from various providers. We'll discuss the impact that's gonna have on the patient, the hydrogenic harm that may happen on the patient, and also the strain on the provider and the system at large. We'll explore some strategies for minimizing strain and burnout. Okay, so here comes the case. So it's a 58-year-old male, presents with alcohol withdrawal. His blood alcohol level is 80 milligrams per deciliter. He reports that he's drinking half a gallon of wine, plus a fifth of vodka every day for the past five years. He does have a history of alcohol use disorder severe. And if you look at his chart, there are all sorts of multiple diagnosis that has been thrown in. MDD, PTSD, bipolar, antisocial personality disorder, malingering. So who actually knows what he has? There's also a chart history of delirium tremens five years ago. However, there's no confirming documentation. He has 12 ED presentations in the last two months for the exact same problem. He was actually discharged from another ED where he completed benzodiazepine taper for three days. And physiology tell us, I mean, if he has completed a taper and he had no symptoms of alcohol withdrawal, it does take time to build back your dependence. So he just shows up the day after complaining of significant alcohol withdrawal symptoms. And given that there's a chart history of delirium tremens, we all know that that's a huge risk factor for having another episode of delirium tremens. So given that history, he was already admitted to the hospitalist service due to this previous chart history of delirium tremens. And even before we were consulted, the hospitalist put him on chloridized epoxide, librium, 50 milligrams every four hours, and put him on CEVA protocol. And then we were consulted for a psychiatric consultation for withdrawal management. So when we showed up, and as I always do for some of these patients, I see them in the hallway first and then go in. He was totally fine, and then upon approach he began shaking uncontrollably. He was just like shaking all over the place. He specifically requested more Ativan. So you can discuss amongst yourself, like what would you do next in this situation? And if somebody wants to come to the mic and say, what's gonna be the next step? I mean, multiple of these options can be true at the same time. You do a physical with vitals, actually you could just do a CEVA. Good, very good. So as we will see in a little bit, there's something that we can do. There's some disadvantages that come with CEVA. There's a lot of subjective elements, and some of the objective elements can be faked by a patient. And physiologically, an alcohol withdrawal picture is a high sympathetic state. So you will see some physiological signs for that with high blood pressure, higher heart rate. So it's really important to do a physical exam. Some of you may also consider doing a more thorough chart review and kind of seeing what's the pattern for this patient and what the prior notes are saying, and maybe reaching out to collateral. So when we looked at the vital signs, heart rate was 88, blood pressure 132 over 88, all of those were his baseline. He didn't have a high temperature. There was no diaphoresis, flushing, or hyperreflexia, things that you may see in somebody going through alcohol withdrawal. Also, it became very clear talking to the primary team that he has been misrepresenting what he has been drinking. So there's a lot of different versions going around. He told the ED provider that he is drinking 18 cans of beer a day, which is not what he told us. So there is a lot of deception going around in terms of what he was actually consuming. And from chart review, it was apparent that he had a history of misrepresenting SEVA, which we will see in a bit how people can do that. Also, he hasn't followed up with any psychiatric aftercare with these 12 ED admissions that he has had in the recent past. None of that actually has led to him falling with any of the disposition plan that was recommended to him. Okay, so now talking about SEVA. So this is the standard of care. This is what we use typically to monitor alcohol withdrawal. And most commonly, it is used as a symptom-triggered approach that if somebody is scoring over eight, it's considered to, patient's considered to have moderate withdrawal. And if the score is more than 20, it represents significant withdrawal. And it really indexes the severity of alcohol withdrawal. It doesn't tell us that who's gonna go into alcohol withdrawal, but if somebody is in alcohol withdrawal, it indexes the severity of the problem. And the problem goes, as we will see on the next slide, is a lot of these questions that are posed to the patient is what the patient would report to the examiner. There's limited objective signs. And patients can over-represent the SEVA score. So these are all the elements. All of them except one is scored from zero to seven. And as you can see, except the paroxysmal sweats, the patient can over-represent or fake majority of these signs. And that may lead to more iatrogenic harm to the patient given the benzodiazepines and the issues that can cause. And just because the patient is having high SEVA doesn't automatically mean that you should just give them more and more benzos, because that can cause harm to the patient with regards to delirium, right? Benzodiazepines are delirogenic. It can cause respiratory suppression, especially in patients who have other respiratory issues. It can lead to falls, over-sedation, and can perpetuate the problem by causing the patient to have a seizure. And can perpetuate the problem with dependence. It also raises the cost because these patients would have a prolonged stay in the hospital and will be taking up a bed that could be used for another person that actually needs it. And that kind of touches upon the ethical principles, right, with justice, with the beneficence. Are you really doing something that's gonna help the patient or giving them more benzos is actually causing more harm to the patient. And keeping them in the hospital setting is actually reinforcing some of this behavior and eventually causing more harm and enabling the patient to come to the hospital seeking for benzos. It does cause a risk for future misdiagnosis. As it was mentioned, one of the bias that is there is the diagnosis momentum, right? If somebody has already a diagnosis of something, when they show in to the ED, you tend to carry forward that diagnosis without really figuring out if they actually really have that or not. And it may lead to unnecessary testing and treatments. So what impact does it have on the system and the provider, right? I mean, we know that 5% of patients lead to about 50% of cost paid by Medicaid. So these high-utilizer patients are a significant burden to the system and to the providers and can lead to significant burnout. And how it may look like in a provider may lead to emotional exhaustion, depersonalization, low sense of personal achievement. And you may feel that whatever work that you're doing is not meaningful. And especially during COVID, it has reached epidemic levels. And how that burnout impacts us can lead to increased physician turnover, reduced productivity, job dissatisfaction, higher absenteeism, having difficulties in your own interpersonal relationships for the providers, can lead to early retirement, suboptimal patient care, high risk for making errors, increasing patient readmission rates, poor physician-patient rapport, because if you're not taking the patient seriously, it certainly affects that, lowering patient satisfaction and lower adherence to treatment plans. So when talking about this patient, it became very clear that he's malingering, right? And what malingering is, is the intentional production of false or grossly exaggerated physical or psychological problems. And we all see this, right? I mean, if you look at the statistics, and depending on the study you look at, may range anywhere from 13 to 33% of patients presenting with psychiatric ED. So a third of your patients may actually may be using some level of deception to get some secondary gain, which may include food, shelter, medications, financial gains, avoidance, going to jail, work or family responsibilities. And the lack of a social alternative really strains the ED, and I think this point was made before. Unfortunately, EDs have become a 24-7 social service agency. And these patients show up with, they want to get things, the only way for them to get them is to show up to the ED, because some of the social support systems are not available for the patient. And ED can be a potential source of food accommodation and psychoactive substances. Some clinicians have recommended using structured clinical tools. However, the diagnosis remains pretty clinical. And even if you look at some of these tools, like the SIRS, it takes about 35 to 40 minutes. So it's not something that's gonna be practical to be used in an emergency setting. And it's a huge cost to society. And the statistic is from 2013, so I'm sure there's an updated number there, which is gonna be more than $20 billion. It's a huge amount of money that gets spent on these patients who are malingering. And it's associated with escalation of behavior and aggression if they don't get what they want. And even though your counter-transference is very diagnostic in these situations, as Kelly mentioned, that patients who are malingering, usually their story is not very coherent, right? People who are imminently suicidal, there's usually a coherence to their story. There's always one thing, that last straw that breaks the camel back, so to speak, right? That was probably true in your case. There's some acute stressor. But with some of these individuals with malingering, it's very hard to get that. There's a lot of vague history, there's a lot of I don't knows. So your counter-transference, even though it can help you with their diagnosis, can be problematic in certain situations. So it's really important to keep that in mind. And there's certainly been instances where one of the trainees that I'm supervising, like if this person is malingering, I don't wanna see this person, I don't wanna spend more than five minutes on this person, and can lead to lapse in judgments and affect the interview documentation and their disposition. There's also this reluctance to diagnose malingering in certain settings where they may be concerned that it may not be reimbursable, right? It's not really considered a psychiatric diagnosis. So they may be concerned about reimbursement or there's a concern for legal liability. If you put that in the chart, if something bad happens, or some clinicians may be hesitant to put that in a patient's chart. And this issue of diagnosis momentum, if somebody has already all these diagnosis carried forward, you tend to take them at face value rather than figuring out how many of those are actually true. So how can you minimize the strain and burnout dealing with these patients? Well, it's really important to have good case management because as I said, some of these patients consider ED to be a social service agency. And some of their needs can be mitigated by effective case management. And there's a lot of burnout in case management as well, but some of these social workers and other ancillary staff in the ED, they very well know the resources and can really minimize these patients who are boarded for a long period of time and giving them the appropriate referrals. It's important to use objective measurement, right? So for this patient, it became very clear from the objective perspective this person was not going through significant alcohol withdrawal. Looking at a chart collateral that can really help you solidify your assessment and your plan. It's really important to identify malingering because if you don't, then a lot of these primary psychiatric disorders that these patients end up piling on keeps getting forward and it'll be difficult for the next clinician to stop the cycle of these reinforcing behaviors. It's important not only to identify malingering, diagnosing it, but also figuring out what's the underlying motivation. One of the supervisors in my residency many years ago said, just because they're malingering doesn't mean that they don't need help, right? So it's important to figure out what's the underlying motivation. For some of them, their motivation may actually be something that they're struggling with. They just don't know how to ask for help or they think by doing this will get the help that they need. It's important to avoid collusion and deception. And establishing an expectation of recovery, that's very important. And sometimes when you do that, when you clarify a thought process that, hey, this is not really good for you, that you don't meet criteria to go to inpatient psychiatric hospital or get the lorazepam, offering an opportunity to give up deception without really necessarily admitting it overtly, this strategy works a lot of times, giving them a face to get out of the situation without admitting that they're using deception. And symptoms abate if the outcome has been achieved or their effort is futile. So while preparing for this talk, there's this really interesting concept that I never really conceptualized. It's also this concept of iatrogenic malingering where people misrepresent their symptoms to gain access to more comprehensive or higher quality care. For some of these individuals, they may not be able to get into some of these MRFs that you were talking about or some of these specialized substance use treatment programs or even get access to a psychiatrist because some of these patients may call and they may get an appointment six months from now. So some of these individuals may misrepresent their symptoms to actually get the standard of care. So it's important to recognize that as well. And really, what that should really lead to is increase in the quality and quantity of our patient and residential services that are available to these patients in the community with substance use disorders. And it's also important to be mindful of not putting in primary psychiatric disorders because sometimes, when you're not really sure, these patients may get put on primary psychiatric disorders which they actually may not have. And what that really leads to is a cycle of false expectation for the patient. They get put on medications that have a lot of side effects. And also, some of these patients may pursue disability because you can't get disability with just primary substance use. And some of these individuals get diagnosed with other primary psychiatric conditions and get on this path where they're not gonna recover because you're not treating the underlying diagnosis that they have, which is primary substance use disorder. And that's the last slide I have. We'll push off questions towards the end. All right, so remember from, you know, some of you are probably old enough to remember the Choose Your Own Adventure book, so we're gonna choose our own adventure and kind of see how this goes. So, and I don't have any financial relationships to disclose, and here's what we're gonna talk about. Discuss some of the different types of biases that we may encounter and how to counteract these biases. All right, so here's a case, LDs, 37 years old. He's got a long history of schizophrenia, and you can see he's currently treated with haloperidol, oxazepam, clonazepam, duloxetine, and paliperidone palmitate. And he's previously tried a number of different medications including olanzapine, lamotrigine, valproic acid, several antidepressants as well, too. And he's also failed clozapine. All right, so he lives adjacent to his mother, and you've been seeing him every two weeks for some time. So a week after the last visit, you get a call from his mom and mom found him covered in feces, not refusing, refusing to shower, refusing to tell him what was going on, but said, mom, I can't shower. You know, I got a lot going on in my head right now. And mom feels he's been drinking heavily, can't prove it. He's been out of the house, acting easily and unsettled. He's afraid. The patient even tells you he's a lot afraid and very scared. So this is definitely a change from his baseline. So by a show of hands, who would want to admit him? By a show of hands, who would want to do nothing right now? All right, so you decide to admit the patient, all right? And then on admission, he tells you, you know, he was trying to figure out a way to die. You know, mom called an ambulance because he was trying to choke himself. He's paranoid that his mother is putting LSD in his drinks. He says he's afraid to drink anything in the refrigerator as a result. He drinks three beers a day and last drank four to five. He drinks three beers a day and last drank four to five days ago. The patient's mother notes patient has been drinking heavily in order to self-medicate. So your next decision point, how many would want to place the patient on an alcohol withdrawal protocol? All right, how many would say, don't worry about it? He's probably not drinking anyway. I mean, he's afraid to drink out of the refrigerator, so he's probably not drinking that much. And besides three beers, isn't that much? All right. So it's good that you decide to put him on an alcohol protocol because he's actually been drinking six beers a day and a half of a fifth of a tequila every day for the past week, which is a bit less than what he drank previously. His stomach can't handle the alcohol. When you admit him, you can tell he's tachycardic. He's lethargic, his speech is slurred. He's incontinent of urine and feces. He had a C of 12. He refused the benzodiazepine replacement and had to get transferred to the medical service. So eventually he got readmitted to psychiatry after his alcohol withdrawal ended. So in regards to the benzodiazepines, because they were added for his anxiety, would you decide, well, he probably was drinking a lot because he was anxious, so how many would decide to double the clonazepam and oxazepam? How many would wanna taper all benzos? All right. All right, so as he continues to stabilize, your interviews become more conversational. You find out he also likes your favorite musical artist and he's an avid bowler, which you enjoy as well. So we talked about negative countertransference. Is this an example of positive countertransference? So he ends up stabilizing on a combination of palipopamotate and haldodecanoate. He's still mildly paranoid, but after five days on the inpatient unit, you wonder if he's ready for discharge. The nurses note the safety plan was reviewed, the patient contracts for safety. He voices understanding with the treatment plan. He agrees to follow up. He's gonna go back to 911 if need be. Mom was contacted, and she agrees with the plan for discharge. She feels he's at his baseline. So you have three choices now. So how many would want to refer the patient for residential substance abuse treatment? Okay, how many would wanna keep the patient a little bit longer to get to know the patient a little bit more? How many would say, well, he's fine, let's discharge him? All right, well, guess what? You try to refer the patient to substance abuse rehab, but good news is his mother picked out a program and is willing to pay for it, but he says he's a homebody, he doesn't wanna go. No amount of encouragement's gonna change his mind. So you end up discharging him. All right, so he was fine, but one hour after discharge, he presented to the ED as a level one trauma. He jumped off a bridge over the interstate, and he was found lying on his side on the shoulder of the highway. He was unresponsive. He was pale with ragonal respirations, had a high heart rate, low blood pressure. He said, I feel dumb. I wish I would have had a better way to go about it. I've prayed about it. I've wanted to die since the day I was born. I'm ready to go to the afterlife. He reported he did not feel he could trust the psychiatric doctors and conceded he did not tell them he had these thoughts during that time prior to discharge. So you can imagine that, right, that you shared something with him. It's not only that he was your patient, but you had some common interests as well, too, and I think we also have to be careful of visceral bias that we wanna punish him for lying to us and how we're gonna continue to treat him again. So eventually he got transferred to a physical rehab facility so he could recover from his injuries. Several months later, though, apparently you get a call from mom. He's the sickest he has been in the past 19 years, you know, with his multiple admissions. Still has severe delusions, think the water's poisoned. Thinks his carton of waters are poisoned. Disgusts her of giving his keys to his enemies. Been using cocaine and alcohol. So he gets admitted again and you can think your own, you know, what kind of bias might you have. You know, kind of, maybe you have a negative transference now. You know, maybe you might think, this person has a fundal attribution error. It's his fault, right, if he'd just stopped using alcohol and cocaine, you know, we wouldn't have to go through this process over and over and over again. But he's been intermittently inherent with his long-acting injectable, but definitely inherent to his alcohol and cocaine. So you have a family meeting with the mom. He agrees that one of the conditions of living property is cessation of cocaine. Again, he improves with restarting the paliperidone and having his brain cleared from the alcohol and drugs. But you wonder, is there anything more you can do? So we have three choices. How many would like to do ECT? Okay, a couple. How many, well, why don't we try to switch to a aripiprazole and transfer to the aripiprazole long-acting injectable? All right. And what about just keeping the current regimen because it's the best it's been for him? A couple. Is he on the long-acting? I'm sorry, he's on the long-acting. Yes, yes, yeah. So it seemed like we had a little bit more for ECT. So the thing about ECT is, hey, you know, he did have ECT before. And the last time he did ECT, he felt everything. And he'll never go through that again. But that was several years ago. And actually, when he was getting ECT, he did a lot better. But you consult your ECT colleague, and who knows, he's progressing to wellness hospitalization for an acute ECT course, you know? And so you could say, is this a framing effect that just conceptualizes this person really just had schizophrenia and alcohol use? And if he just would get his drug use under control and his schizophrenia under control, we don't need to go the route of ECT. Eventually, you do discharge him. So, and he gets discharged on the current regimen. And so this is another bias we have to also think about. You know, we've invested so much time into this, you know, that this medicine is gonna work. We know this regimen's gonna work. But sometimes we don't wanna think about other options. You know, sometimes we also might think, you know, I think as one of our presenters talked about before, that, you know, is this as good as it gets? You know, sometimes we don't necessarily believe that our patients are gonna get better. And so we just maintain the current status quo. So, but after discharge, the outpatient psychiatrist notes, you know, he's doing okay. He's still paranoid, he's lonely. He's afraid that his brother might give COVID to his dog. Denies cocaine use and drug screen was negative. So, and he, you know, he's still drinking a little bit as well, too. You know, and so the plan at that visit was, hey, he's still, he's not perfect, but, you know, we're gonna do the long-acting paliparadone in a couple weeks. And, you know, he says he's kind of feeling terrible after his injections, but, you know, maybe we can reduce at the next visit. We'll kind of see. So, you know, so we, and you know, as some of our presenters already talked about, you have to think about, you know, the data, you know, how do we prevent this in ourselves? You know, are these relevant data, you know, as we're talking to the person? You know, are there other things that are going on besides just the obvious causes? You know, how did I reach my diagnosis? You know, it's, a lot of times it's easy just to follow things in the chart and just carry them forward. Like in Dr. Munjao's case, you know, his patient had delirium tremens in the chart. Well, did the person really have delirium tremens or was the person just having shakes, you know, during, as his alcohol withdrawal? You know, did a patient suggest a diagnosis? I mean, you know, sometimes patients will look up their symptoms on Google, you know, or even a treatment and say, hey, what do you think about this treatment for me? And you think, oh, that's a great idea. Maybe I'll, maybe that is the best treatment for you. I saw this commercial on TV. You know, am I asking alternative questions? You know, am I interrupted? Am I distracted by caring for the person? You know, is this a person I do not like or do I like them too much? You know, as I said, you know, a lot of, we all know of patients we don't like, but you know, what about the patients that we do like? You know, that we have a commonality with when they come into the office? You know, any stereotypes? I guess here's the last thing. Remember you are wrong more often than you think. I think that's really hard because we got into, we passed medical school because we were right. You know, not because we were wrong. And you know, and so you have to really humble yourself that, you know, hey, you might be wrong. And you know, the other thing that's not on this list, but we've talked about it, you know, consult a colleague. You know, a lot of times psychiatry can be isolating at times, you know. And so, you know, it's important to talk to your colleagues, you know, about challenging cases. So that's all I have. All right, thank you all for hanging in there with us. I have to lower this, I am shorter than all of them. We are gonna do some question and answer now. So if anyone has any questions, please feel free to step forward and we'll begin. A question about the first case. I saw the diagnosis of dissociative identity disorder, but were there other diagnoses, particularly borderline personality disorder? Yes, so there was a lot of diagnoses, as you might imagine. There was depressive disorder, there was borderline personality disorder. And interestingly, towards the end of her life, after she came back from the hospital that specialized in dissociative identity disorder, the outpatient primary team was trying to figure out if she had some sort of addiction to the self-mutilation. So they were trying all, they were just throwing the kitchen sink at it. But was anybody talking to her about borderline personality disorder and being explicit about it? Because there's a, one of the things that we, physicians do, and I try to teach the second year residents how to do this, is that we don't use that word because of our problem. It's not their problem. And this is not cancer from 75 years ago where we just don't say anything. We actually should say something so that they can actually learn about the illness, what to do, and all these things. And it makes, it takes away a lot of the contests in the emergency room when you can talk to the person and say, look, you know, inpatient's not good for you. After three days, you're gonna be in terrible shape, and that's your experience. You know that, we know that. So is there another alternative besides thinking that this is the only way to go? Among other things. Yeah, absolutely. Same shelf life as fish. And also framing, in a way, what the borderline personality disorder, it's actually a curable diagnosis. How many psychiatric conditions are curable, right? None of them are. So I mean, so I actually say it as a good news to the patient that this is something that with treatment, there's a very high chance five to 10 years from now, you're not gonna meet the criteria anymore. And I also want to point out that I think in your presentation on that same patient, you repeated a couple of times, she was very nice. She was. Always smiling, very pleasant. Yep. And so I think actually bringing up the diagnosis, it opens the door so she can actually express how she feels inside, right? Because what she presents on her face is, I wanna give you what I think you want, which is a pleasant, nice patient. And meanwhile, I'm gonna carve things on my arms. And she's coming over and over, communicating with the carving, because she cannot say it. So if we help putting words and saying, this is the illness, this is what's going on, this is what's going on on your brain, I think you can take the treatment in a completely different direction. Thank you. Partly opinion, but how do you address the misuse of the term behavioral, especially by staff, which in my opinion means, I don't know, figure it out, I don't care. It's not worth my time. What do you say? So that's an interesting question, because in the state of Vermont in particular, we don't use the term behavioral. We don't use it. As far up as we have behavioral health centers that now have to have their name changed, actually. So it's at state level, we're taking away that term behavioral health, because it has an implicit bias towards it that the person's doing it on purpose. And a lot of times this comes from a psychiatric illness or from coping skills that are maladaptive or adaptive. And so we actually address it very, very head-on of we don't, this is not just a behavior, there's something that's causing this behavior. And so what's more helpful is if we look at what's actually causing it, than just labeling it as a behavior, because that's a write-off, right? It's just saying, I don't need to worry about this, because it's a behavior. I'm curious what the others have to say, though. That's a very, very interesting and good question, because I think I've struggled with that myself personally. So I'm a child and adolescent psychiatrist by training. I only do inpatient child psychiatry, and I get a lot of kids who are in the foster care system who are in residential treatment facilities. So whenever a lot of these adolescents who come into the emergency room, because they don't want to be at the residential treatment facility anymore, my staff immediately tells me, oh, this is just behavior, right? I mean, this is just behavior, this person's just trying to do this to get out or just wants a break from this residential treatment facility, and I have to consciously remind them over and over again, okay, let's assume that this is behavioral, but it's still dangerous, right? Just because it's behavioral, quote-unquote, that does not make it less dangerous. This is still very concerning, and I think that repetition over and over and over again, I think over time has decreased. The amount of times they kind of just have this bias, oh, this is just behavioral, we really don't need to help this person per se, because that's the implication, right? Do not admit this person because this is just behavioral. That is the implication. They're not saying, oh, yeah, this is behavioral, bring this person on. And I think having that conscious repetition, I think it begins from us, because I think if we as leaders of the treatment team really bring forth that concept that even if this is behavioral, this is still very dangerous and we still need to help this person, I think that does trickle down, and then as an interdisciplinary team, we can really address the root causes, like Dr. Klein said, of why are these dangerous behaviors occurring in the first place? Yeah, and I think along those same lines, once the person gets admitted, we also have to manage our countertransference as well, too. Someone acts out on the unit, and you wanna say, this is unacceptable, get him out, but the person's in distress, and what is going on, and even the term behavioral, right? I mean, aren't there positive behaviors that people do? We just use the behavioral, it's all behavioral, it's all negative. So I had never thought about the term behavioral health as being biased, so. Yeah, I think thinking of it in a way, it's just a symptom, but what's driving it, right? If somebody shows up with fever, you figure out what's causing that. So I think focusing on that, what's kind of driving this, rather than just focusing on the behavior itself. And if anyone wants to read a little bit about some advocates with very strong opinions about the term behavioral, you can look up the journal CounterPoint. It's published in Vermont from our Vermont Psychiatric Survivor publication. There's a lot on it there. One way is to have a CMS case which is what happened in our situation and we had a system-wide implementation of a training and it was a lot like Dr. Kimball's choose your own adventure and every person that came to the emergency department so my husband who does OBGYN had to do the training he was not very pleased but everybody that comes to the emergency department has to do the training now so trainings are a great way. No I would definitely say definitely visit the HHS.gov website I think those class guidelines are very very helpful to kind of guide us on how to train with with our biopsies I think and of course there is nothing greater than a CMS visit to your hospital because that just brings up the alerts and so to prevent a CMS visit I would say at least look up the class guidelines those are very helpful. I mean you know those of those with us who work with trainees it's repetition over and over and over again and you know unfortunately as trainees move on or change to different rotations over and over again and the same thing with EMS as well too you know you're gonna have different providers you know different nurses you know it's over and over and over again. Just gonna keep up with education I mean there's so much flux in in staff that you know you just have to you know make sure these trainings and these educational content is delivered to them periodically. I can try and take that one because this has happened to me multiple, multiple times and I have tried to be, I think Dr. Azov can attest, very sweet, very kind about it. And at some point I just have to put my foot down and say, too bad for you, this is happening. And I don't want to be that person. I want to be liked, right? This is probably my problem. But at some point, I just put my foot down. This is happening. Too bad for you. I'm not going to provide care to this patient. And would I want it to not reach that point? Absolutely. But at the end of the day, I still have to do right by this person who's presenting in crisis. Right. And remembering you have one job, which is to provide standard of care for that patient. So even if the inpatient unit says, no, I'm not going to accept them, you're still doing your job. You're recommending an inpatient, whether it's at your hospital, another hospital, you're not going to change your medical opinion based on acceptance. Yeah. I was curious what happened to the gentleman in second case after gabapentin and neurocognitive disorder. So that was a very interesting point because I think he took more gabapentin than what we believe he actually took. And he drank way more alcohol than really originally presented. Sounds like he did have a lot of cardiac comorbidities that were very serious and ended up passing away from cardiopulmonary failure. All right, well, thank you all for attending our session today. Clap for us.

provider bias

patient care

psychiatric services

Kelly Klein

Vermont Department of Mental Health

instant countertransference

high-utilizer patient

alcohol withdrawal

Medicaid costs

burnout

implicit bias

clinical decision-making