Where, Indeed, Is Our Health Care System Going?

I hope you can read the article in the tweet above in its entirety; this is the first time I’ve ever been able to access full text papers in Psychiatric Annals on line. It caught my eye and not just because the title reminded me of a TV comedy anthology with love as the theme, “Love, American Style.” It did strike me as ironic though, especially when I compared it with the blog posts of my colleagues, also tweeted below:

I think Dr. Dawson’s post about psychiatric patients who are violent, in which he briefly refers to a recent news story about a psychiatrist shooting a psychiatric patient who shot and killed a psychiatric caseworker in Pennsylvania, was well done. Dr. Dawson’s description of the danger inherent in caring for violent patients and how our health care system fails health care professionals is chilling.

And I was similarly struck by the post Psych Practice blogger wrote about a Jewish doctor who, while researching his book on the subject, interviewed physicians who tortured and ordered the killing of Jews in Nazi Germany. The blogger wondered about the risk of the author identifying too much with the “humanness” of the Nazi doctors.

I’m sure George would have a lot to say about Dr. Wang’s historical breadth and depth on where our health care system has been and where it seems to be going. After all, he’s been there, done that. I disagree that the AMA should be given much credit for representing rank-and-file doctors. Only 16% or so of physicians are members. In fact, the AMA did finally end up endorsing the Patient Protection and Affordable Care Act (PPACA or Obamacare) which included the disastrous clause outlining the so-called “incentives” now to be replaced by penalties from the Centers for Medicare and Medicaid Services if physicians don’t comply with Maintenance of Certification Physician Quality Reporting System (MOC:PQRS). And I’m not impressed by a savings in private health insurance administrative costs being cut from 33% to 15%-20%. There are other costs besides dollars and cents in the constant effort to safely manage violent psychiatric patients. We need to talk more about the price paid every day by mental health care workers–sometimes including their lives.

I’m reminded of our own hospital’s efforts to manage violence, namely our Code Green interventions on the psychiatric wards and in the general hospital and emergency room. Several times a week, I’m called to Code Greens in the latter two areas. The Code Green team consists of nurses and doctors who rush headlong into sometimes explosively violent situations in which delirious and behaviorally disturbed patients (and even visitors) threaten their own lives or the lives of others. I marvel that gun violence has not yet erupted in the 18 years I’ve been paged to Code Greens.

The Code Green team at our hospital consists of a group of people specially trained to use non-violent measures to help patients who are violent get under control in order to minimize the risk of injury to themselves and others. These events are often intense encounters in patient’s rooms, hallways, lobbies, and other places in the hospital where patients who are confused and out of control can wander. First and foremost we try to contain the patient to maintain everyone’s safety, and then ascertain why the patient is confused and at risk for imminent violence or already perpetrating acts of violent behavior toward themselves and others. This has to be done quickly so as to minimize injury.

Although the two video skits below made by talented former residents demonstrate violence management including Code Greens in a humorous style, in real life they are anything but funny:

It’s difficult to identify with the humanness of someone who is threatening me in a Code Green situation. While we’re lucky at my hospital to have the Code Green system, it’s almost impossible to apply it outside of our medical center. All I can manage to say in my sorrow over what happened in Pennsylvania is, who am I to judge?

This makes me wonder where, indeed, our health care system is going. We’ll need more than our Professional codes and ethics to protect both us and our patients. Some government regulation may be necessary, but not so much that it drives away doctors. Now more than ever, we need to listen to each other.


Wang D. Health Care, American Style: How Did We Arrive? Where Will We Go?. Psychiatr Ann. 2014; 44: 342-348. doi: 10.3928/00485713-21040707-08 [link]

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