Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.