Tuesday, May 16, 2006

Change is Good




I've been in corrections long enough now that my name has become inextricably associated with prisoners. Free society clinicians occasionally call me and the call goes something like this:

"I was supposed to see Joe Blow** and he didn't show up for his appointment. Could you check and see if he's been locked up?"

Or:

"Joe Blow's sister called and said the police picked him up last night. Could you make sure he gets his medicine?"

For all practical purposes, I've become the local lost-and-found for psychiatric patients. That's OK. I like talking to free society clinicians, particularly the part where I tell them: "Yeah, he's already been seen. I saw him the day after he got locked up and his meds have been ordered."

There's always a bit of a silence at the other end of the line, or a general expression of surprise. People are so used to hearing stereotypes about correctional mental health care---universally negative---that they can't believe a system could ever possibly work well.

On my end of this process, I have a wish list.

I wish that clinicians who call me about their patients' medications would actually know the medications that the patient is on. As in, the name, dose and frequency.

I wish the free society medication regimen would make sense. Granted, psychiatry is as much of an art as it is a science so psychopharmacological approaches can vary reasonably between reasonable clinicians, but I see some med combos that don't come close to reasonable. I get patients from free society who come in on subtherapeutic doses of two or three medications from the same medication class, or on meds with no proven efficacy for the diagnosis the patient has been given. And I am responsible for making treatment decisions given this history.

Sometimes I change medications from what a patient was given in free society. I know this is heresy, and it tends to engender suspicion from my patients and/or concern from outside parties, but I do it. I do it when I want to give treatment that is consistent with current practice guidelines and research. I do it when there are known contraindications or potential complications (like addiction) associated with the free society regimen. I do it because sometimes the patient actually may require less--or no--medication once he/she is abstinent from drugs and alcohol. I do it because I am responsible for doing what's best for the patient, even when the patient demands care that is outmoded or even inappropriate.

Yes, I change things. But sometimes things need to change.

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**Not his real name. Duh.