The Public Hospital, Part 3 or, Ah, Sustainability

October 30, 2006 at 2:15 am (Michael's Posts)

At long last, the screening project I am working on at County is underway  (see past posts on the Public Hospital for an outline). I’m starting to work with two attendings in the outpatient clinic who are hip to the project’s aims of providing more information to docs about their patients’ mental health and substance use patterns.  Definitely fun and I’m looking forward to expanding my interviews to other doctors’ patients.
It’s absolutely two different things to talk about doing “depression screening” and “alcohol screening” and actually asking people about their emotional state and drinking habits. I haven’t seen that many people yet, but I have already had a good number of people admit to me, at times tearfully, that they are “hopeless” most days of the week. When I hear about the economic circumstances they survive from day to day, I am increasingly sure that I might feel hopeless in their stead as well. Is medication the way to get at their hopelessness? They might blunt the pain a little bit, thus causing the symtoms to subside, but they cannot disappear because the root is still deep in them.  Psychoanalytic counseling probably won’t alleviate their suffering. This is why I am an economic radical. There may be socioeconomic solutions that would reach farther than any band-aid that medication could place on this deep, festering wound.  I am on the lookout for them, as I believe we all should be.
The really sad part for me has been hearing the truth that this project will likely be as short-lived as my year of volunteer service. Even if they were to get a grant, the project wouldn’t continue for more than a few years because grants for things like this run out and aren’t renewed. The project should be sustainable in order to have the best effect because the screening is all well and good but the follow-up is the important thing. I don’t know whether that’s the job of the screener (whoever that is) to do follow-up or if it’s the job of the docs to take the green light from the info we give them and follow up with their own patients. But with the great strain already placed on the time and energy of the attendings at the clinic, the project’s creators have limited faith that doctors will be willing to take up the cause. They already have enough on their plates. The two docs I am working with now hope that being able to reach their patients just a little bit better will make it worth it to the doctors to continue the process I begin. Hopefully this is not unrealistically optimistic.  Then the only trouble is finding someone after I leave to continue starting the process.  Or teaching the doctors how to start it themselves.  But then the issue of time restraints… It’ll be interesting to see how this unfolds.



  1. sstolper said,

    Michael, can you give me a more in-depth explanation of your job? Specifically, your daily pattern. Do you meet with a doctor or counselor every day to plan or update or whatever-have-you? How many patients do you see? Is the screening very scripted, or do you ask questions as the conversation brings you to them? How much creative freedom/independence do you have? It sounds like there’s so much going on with your superiors that you have room to go whatever direction you want.

  2. msoule said,

    Hey Sam, sorry it took me a bit to get back.
    My day at the clinic starts at 8:30 or so. I get one of the exam rooms that is open and set up my little printer and my laptop. Then I go to the nurse’s station that is located behind the magic doors that separate the waiting room from the Firm itself (the outpatient general medicine clinic is split into 3 firms: A, B, and C. I work in C at the moment. Each firm has its own 4 or 5 nurses, 3 or 4 attendings who have morning clinics, and 8 or 9 residents who have afternoon clinics). At the nurse’s station, there is equipment for doing vital signs for patients whose charts have been pulled from records up to the clinic. Each provider has a pile of charts with their name on it, usually between 9 and 14 patients per morning of work. I go to the chart at the top of the pile, open the magic door, and call the patient whose chart it is. I introduce myself and we head to the exam room.
    There, I give a little preamble about the questions I’ll be asking and I give them the opportunity to ask me any questions they might have as well. Then I ask them if they’ve ever smoked and go through a little flowchart of smoking questions. Then I ask them about illegal drug use, depression, and alcohol use. Each has a little flowchart that opens with a few gate questions which, if positive answers are given, lead to other questions in that vein. If a patient screens all negative, screens take 3 minutes. Most of that is preamble. If a patient screens positive for depression or concerning levels of alcohol use, the screens can be 10 minutes long. I try to get there early so I can beat the doctor to the top of the pile by about half an hour. This is so if I get any positives, I can do a full screen and it won’t mess with their place in line. The waits, as you can imagine, are astronomical.
    At the end of a screen, I usually tell the patient how they screened and ask them to continue the conversation about areas of concern with their doctor. I also pop a little print out of the relevant results and also relevant services that can be recommended for those patients. For instance, for alcohol users we have a sheet with some of the rehab centers that get referrals from County. This sheet only uses the patients’ medical record number and not their name and it goes in their chart for only their doc to see.
    When I get a positive screen that is of real concern, I usually tell the doctor whose patient it is and give them my impression of what was going on. I tell them what I asked and how the patients responded.
    I usually do tailor the conversation to the patient. There is an order that the questions go in but sometimes, I’ll switch up the depression questions because some of them are pretty intense and if I feel that a patient is feeling really bummed, I’ll ask a few lighter questions (ha!) before I get back into the deep stuff. I also have a lot of freedom in terms of rewording the questions because many of our patients don’t really understand the way a lot of the clinical psych and substance questions are worded.
    In truth, I have quite a bit of autonomy but I am also trying to get information in a certain way so that the numbers that come out of my screens fall in a certain meaningful range and the docs can interpret them with said meaning. So I don’t change meanings of questions when I change the wording (at least I hope I don’t).
    Is that what you were asking? I feel like that was a long answer and maybe I missed some notes…

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