Saturday, November 18, 2006

Medical Director made to resign for speaking up for teen murder suspect stuck in the ER


There's really nothing good about this story at all. But I'm interested in it from the access-to-care angle.

A 16 yo kid in California, two days after being taken to a priest for help with voices, is being accused of beating his mother to death, and was being held in the psychiatric ER for over a week, waiting for an adolescent psych bed for further evaluation. Apparently, no one had been able or willing to take him in on their unit.

The psychiatric unit at Contra Costa Medical Center is reported to only be licensed for adult beds. According to the news article, the unit medical director, Scott Weigold, made a stink about the kid's clinical needs trumping policy constraints. Sounds like he made no secret of his concerns (broadcasting the email to staff), was accused of insubordination (are they in the military?), and is essentially being told to not let the door hit him on his way out.

He e-mailed Dr. Jeff Smith, the hospital's executive director, saying he planned to admit Mantas to the hospital's adult inpatient unit.

"I explained in very ham-fisted and emotional manner, that I was desperate to prevent a young man needing psychiatric hospitalization from being required to live in (psychiatric emergency services) for another week or more," Weigold wrote in a letter distributed to his colleagues this week. "I demanded that potential licensing and regulatory issues ... are not sufficient to prevent us from providing this young man the only form of inpatient treatment available."

[...] Contra Costa acute-care facilities for adolescents accept only people who meet strict criteria for being held against their will, including being gravely disabled by mental illness or posing an acute danger to themselves or others, Smith said.

Contra Costa Regional Medical Center is not licensed to provide inpatient treatment to youths and does not have staff members credentialed to do so, he said.

Smith e-mailed back to Weigold, accusing him of insubordination and stating that he considered the e-mail to be Weigold's resignation.


I don't have much to say about the kid, but I do understand Scott's frustration. We see less burdensome kids in ERs for a week or more around the state. It does sound like he went about making his case in a less-than-effective way. However, I'm guessing that there is more to this story than mentioned here. For example, Contra Costa was in the news last week about closing down nearly half of their psychiatric beds, citing insufficient community need (this hospital is in the San Francisco area). But advocates are crying foul:

[Danville resident and advocate Nancy] Thomas raised questions about a loss of federal money for the psychiatric unit because of a dispute involving the qualifications of people overseeing it.

The Times reported last week that the U.S. Centers for Medicare and Medicaid Services will deny a higher Medicare reimbursement rate for this year, a rate the county has received since at least 1998.

To obtain the higher rate, the federal agency said the director of inpatient psychiatric services should be a psychiatrist -- he is a licensed clinical social worker -- and the unit's nursing director should have a master's degree in psychiatric and mental health nursing or comparable experience in caring for the mentally ill.

"Why would you leave $2.8 million on the table to just slip away?" Thomas asked county officials. "Why not keep those beds open?"

They were also in the news yesterday being accused by CMS of inappropriately transferring uninsured patients with psychiatric problems to other facilities... the article suggests that Scott started that policy. CMS said it would terminate its Medicare contract if the problems did not get fixed soon.

Getting clearer now... Most inpatient units have a medical director; in part, because of the above reason, but also because it just makes good clinical sense to have the person setting the rules be one with full medical training. Apparently, the social worker runs the show. Now, I'm not knocking social workers, but an inpatient unit providing medical treatment and medications should have medical oversight. N'est pas? Perhaps this was merely Scott's last straw.

* * *

BTW, I also note that Scott backed up Dr. A 5 years ago in an exchange on an antipsychiatry site (http://www.antipsychiatry.org/e-mail.htm#debate2). Wonder if it's the Dr. A we all know and love.

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13 comments:

Sarebear said...

Dadgummit!!! Stupidity.

I'm frustrated with lack of access to care issues in Utah, too. I spoke w/Governor Huntsman and the Deputy Director of the Department of Health & Human Services for the State of Utah about it.

STUPIDITY. Ugh.

dinah said...

There was a lot there and a bit hard to follow.

I'll have to go back and look at the article.

A "Medical Director" without an MD?? At the very least he needs a new title, perhaps Unit Director or Program Director or Admin Director.

I did look at the anti-psychiatry link you posted, and Dr. A there is a psychiatrist, not a family practitioner, and Scott Weingold is a Psychiatrist (an MD) and not a social worker, so I don't think any of these people are the same.

What a story. I have to say, IF I was running an adolescent unit, I might have a hard time wrapping myself around admitting a kid who had just killed someone in a psychotic state. And if I was the parent of a child on a unit that admitted that boy, I'd be freaked. I don't know any details, but at 16 one would think he'd need placement in an adult forensic facility for those who are dangerous. An ER doesn't sound like the right place either. I may be totally off-base here knowing nothing about this tale.

What an awful story.

ClinkShrink said...

That's an 'uffda' situation. I find that whenever there's a tension between clinical need and policy, the policy always wins. The overarching drive to preserve political relationships will always win over common-sense patient care issues. As Dinah pointed out, the obvious complicating factor here is the fact that the sixteen year old was a forensic patient---one of our hot potato cases. Forensic beds are about as rare as adolescent beds.

These kind of situations are the rare times when judges can actually do some good. As much as I've ranted about judicial clinicians, they can do a good job of getting the system to 'shut up and behave' when necessary. They can enforce a physician's clinical judgement over policy.

Gerbil said...

Awful, but I can't say I'm surprised. I live in the next county over and used to work in Contra Costa, though not for the county itself; so this topic is pretty near to my heart, geographically and otherwise.

California's Proposition 63 (the Mental Health Services Act of 2004) is supposed to provide funding for county mental health services at all levels. But unfortunately all those monies have to go toward starting new programs--not toward fixing existing financial messes. Contra Costa is planning (and now implementing) all sorts of new things, but the basic issues remain.

Another wrench in the works is that along with beds, a lot of MH jobs were/are being eliminated. But there's still a need for staff, so many of the positions are now open-ended temporary spots. No security, no benefits, no definite path to permanent employee status despite the union's ongoing negotiations with the county. Oy vey.

Dr. A said...

Yup, that was not me. I was still resident Dr. A back then. Ah, to be back in residency....

As far as the access to care thing, it's a real problem. I know I've said before that we have zero psych beds in this county, and we have to beg neighboring community hospitals to admit our psychiatric patients.

Outpatient psychiatric services around here is sparse as well, because of lack of state funding.

I feel a rant coming on, but I'll hold off for right now...

Sarebear said...

Part of the problem with the state funding, is problems w/federal funding. One of the main reasons access to care is pretty much not there for the working poor, those above medicaid level, but can't afford insurance, is because the federal government cancelled it's funding of certain things (I still need to get specifics, so I can meet w/my state legislators, relate my personal experience (which I was told is exactly the type they need to hear), go over what I think, and push for change.

See, this was 7-9 million in funding for county mental health that was cut, not because our state did anything wrong, but the federal government just cut it. MH cuts have been happening and the 90's/2000's have been really bad for that. Anyway, so the state had to pick up funding for it, but they didn't fund it near at the level the federal government did.

So I, two years ago, being suicidal and looking for help (no plan or imminent, but was feeling like it was going to go there, if I couldn't access mental health care/hope, at the time), the county mental health system was my last hope. 10 years ago, they took patients on a sliding fee scale. Two years ago, they could not and would not take me at all, without funding on my part from certain sources. Which sounded wierd, as they wouldn't say, but I'm guessing medicare/medicaid, or something, because why not just outright say insurance either.

I walked away in tears, feeling as though society just did not want people like me, or to help people like me, who couldn't afford to help themselves, but wanted to heal to become a productive member of society (which is best for society in the long run, too, besides being good for me). Seriously, there was nowhere else to turn, and I pictured others like me being turned away, and it made me angry. Which is why I eventually spoke to the governor and that state dept. of H&HS about it. The head of that dept, as well as the governor, are frustrated by the federal govt on that, as well as by the legislators who only funded it half arsedly.

Altho having to scramble for that since the feds pulled the rug out from under em, is not entirely their fault.

SO! It's a mess, anyway, on my levels in many areas. This is some stuff I found out, that I'm going to do more work on and stuff. And of course blog about my progress on, etc.

It was something I found thru this blog that gave me the courage to dial the numbers to talk to the governor. Let me tell you I was scared to death!

Anyway, that's what I've been doing about it, because somebody's got to.

Sara

Roy said...

Sara-good job talking to your guv. That's the sort of thing that needs to be done -- with governors and legislators in each of our counties and states -- so they here about how these problems affect their constituents. Also, offer them suggested solutions. They love that. They don't have to be comprehensive, but it gets them thinking about possibilities.

Gerbil-thanks. Keep us posted.

Clink & Dinah- yeah, I'm guessing that if I brought that kid onto my unit, some staff would threaten to quit, etc, and the turmoil caused by "doing the right thing" would result in diminished care for the kid and others (and reduced job security for yours truly). Policies are in place to reduce the chance tht we'll do things that make sense at the time, but that have lots of negatives attached to them.

Alison Cummins said...

Sarebear,

I know what you’re talking about. Not the bit about calling the governor, but the bit about being turned away when you’re at the end of your rope. About doing everything you know how to do and being told it’s not enough and to come back when you can be a better, more together person — preferably one who doesn’t need psychiatry. I feel sick just remembering.

Fortunately I live in Canada, so while bureaucracy, politics and snottiness are just as much a problem here as anywhere else, I at least have guaranteed health insurance. All I have to do is show the card that all residents (no, you don’t need to be a citizen) have. No paperwork. At all.

I have both a PCP and a psychiatrist I see as often as I like. The government pays them.

Around eight years ago, the province where I live introduced universal drug insurance. I was able to start taking Zoloft. (I show up at the pharmacy with my health insurance card and they hand over free meds. Again, no paperwork.) Within a year my income had quintupled. My life has completely changed. The taxes I pay now are much higher than any burden I might represent to the system.

Consultations with a psychologist are not covered through universal health insurance though. There are some ways of getting free psychology consults but they aren’t very good. Through the job I have now I have an insurance plan that pays for about seven appointments a year. Fortunately I don’t need to see a psychologist that often.

Ultimately in my case it was just a case of knocking on enough doors. Once I found one that was open everything was peachy. Money is not an issue. I have money now, but if I were to be on the street tomorrow I would have access to exactly the same psychiatric supports I do today. And they’re plenty good enough.

If your governor wants suggestions, single-payer insurance is a good place to start. (My grandfather is/was a doctor in the US, by the way, and a strong supporter of single-payer.)

In any system, psychiatric patients will be the ones pushed to the back. Anything we have to say has little credibility because, well, we’re psychiatric patients. And many of us have trouble getting organised to vote. This is where we grit our teeth that life is so unfair, and are grateful if we happen to have friends or family who can advocate for us when we need them to.

But making us arrange for services to be paid for? When it takes all we have just to pick up a phone, never mind dial? That’s just sadistic.

Alison Cummins said...

Oh, I’m trying to use Google to find stats on Canadian psychiatric beds: no luck. All I can get is variations on “better than Australia” or “better than the US,” and most data is 10 to 15 years old.

I’ll see if I can keep looking.

Dinah said...

Oh, by the way, I've been meaning to say this for weeks now, but my sense from the article is that "Emergency Services" (could be anything anywhere) may well be something physically different from the ER (think guerney in the hall or concrete seclusion room with mat on the floor). It's a vague term at best.

Anonymous said...

so, you all write confidently about a story most or you never even bothered to read for yourselves - just read the vague summation on Shrink Rap - and then start declaring summary conclusions. Not one of you bothered to actually find out anything more before talking as if you know one single thing. Let me know if anyone bothers at Shrink Rap bothers to learn of what they speak. Here is what Dr. Weigold wrote:

"There is a plan to close 4D and re-deploy those resources in ways that will reduce the patients’ need for hospital admission. I firmly believe in that philosophy. As the planned date (11/13) for ceasing admissions to 4D approached, I learned that none of the promised resources for patients arriving in PES were available and could find no evidence they were even pursued. I wrote an email pleading and demanding that the multiple promises be kept and patients permitted admission to 4D until those “safety-valve” resources are available. In addition, I explained in a very ham-fisted and emotional manner, that I was desperate to prevent a young man needing psychiatric hospitalization from being required to live in PES for another week or more. I declared that potential licensing and regulatory issues (which a DHS supervisor told me do not exist) are not sufficient to prevent us from providing this young man the only form of inpatient treatment available. It was not my best moment by far. I cannot claim I was blameless in how the events unfolded.

Hospital Director, Dr. Smith then emailed to Dr Walker, HSD top staff, PDOCC union representative, Director of Human Resources, and County Counsel that he “accept(s) your insubordinate e-mail as your way of resigning from Medical Director of the PES and Inpatient Psych. Thanks for your time, too bad you can’t seem to function as a ‘can-do’ team player.” Also, this comes after his repeated promise that he will stand by the staff and patients at PES by refusing to permit the closing of 4D unless there is guaranteed access to inpatient beds over and above the remaining 23 beds at CCRMC – at least until the outpatient resources designed to eliminate that need are up and running."
The psychiatric unit in question did close with no resources available for patients. The young man was never admitted to any hospital, but instead returned to juvenile hall without appropriate treatment because the adolescent psych units in the area refused admission of the patient on no grounds other than that it would be a bother. The continued destruction of psychiatric services in Contra Costa County continues - not because of any evil conspiracy, but because there is simply no plan.

ClinkShrink said...

OK, I've read your comment but I don't see the point you claim we've missed. Quoting Dr. Weigold's email in full basically reiterated what we already knew---he was passionate about trying to provide inpatient care for someone who really needed it, and as a result was fired for it. Both we ShrinkRappers and our readers have commented in the past about the lack of inpatient resources for adolescents and forensic patients and one commenter on this post talked about what's happening in California. We get that part because we're all living it.

Regarding your statement: "The continued destruction of psychiatric services in Contra Costa County continues - not because of any evil conspiracy, but because there is simply no plan." I believe you. Unfortunately, this is how government appears to work (using the term loosely). Another example of Hanlon's Razor.

Roy said...

Anon- I also don't get your point. Sounds like we are saying the same thing. You got a raw deal trying to do what is right, and it is being turned around to make it look like you did something wrong. If anything, I'd think that APA or NAMI would give you a Profiles in Courage award or something.