Navigating the ambiguity around whether to admit or discharge


In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.

Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.

Dr. Jacqueline Posada
On any given night, our urban, downtown emergency department is chaotic, whether from the trauma case arriving minutes earlier or perhaps the patient high on PCP shouting from the “quiet room.” In the ED, psychiatric patients are placed on elopement precautions and assigned to recliners or beds near the center of the ED so they can be watched by sitters. These patients, who come to the ED with a chief complaint of emotional suffering, are exposed to the epicenter of the controlled chaos.

If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.

When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.

The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.

However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.


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