Wednesday, December 19, 2012

We Live in a Crazy World

Please, please, I must beg your forgiveness before posting this.  Sometimes, I just wish the world made sense, and it doesn't.  I should get over it.  

There is the story of a psychiatrist in France who was criminally charged with murder because a patient left and then, 20 days later,  killed someone.  The psychiatrist was found guilty and I believe she paid damages.  I think ClinkShrink may write about this on Clinical Psychiatry News in the coming weeks, but for now, I just couldn't resist the sarcastic pull that overtook me when I saw this...the psychiatrist guilty for another person's murder, the horror of our gun laws, and the ridiculous new CPT codes we will all soon be using.  If you are touchy about satire, please don't read anymore.
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 French psychiatrist jailed for patient who committed murder
Here's the  missing back story.  During the consultation from which the patient fled, the psychiatrist was trying to figure out whether the several sentences the patient said about his episode of syphillis constituted psychotherapy or whether they were related to the medical aspect of the patient's care.  Should she utter supportive words, and tell the patient he may not have infected all 50 women he'd slept with [psychotherapy, supportive in nature], or should she suggest further testing to rule out possible neurosyphillis [medical intervention]. Would it take long enough to discuss and therefore be 25.1 minutes, so over half of the session would be devoted to counseling, and if she arranged for transportation to bring the patient back for an LP next week, well there's the coordination of care, and the documentation could be punted.  Oh, but unfortunately the patient began to talk about his father -- how mean, uncaring, and critical he'd been which had lead him to seek solace in the warm sweet bodies of prostitutes and could this relate to his relationship with his emotionally distant mother? So now the possibility of time-based medical management was lost, and an add-on code for psychotherapy became imperative.  The patient rambled on.  The doctor suggested they look at other similar relationships, were his sisters cold?  His aunts?  What about that favorite neighbor, Ester?  Oh, gosh, the doctor had now gone to 51 minutes of psychotherapy, so close to that 53 minute threshold for a higher add-on code and so much more reimbursement, when the patient announced, "I've had awful diarrhea from the medication you've been giving me?"  The doctor could take it no more and tried to sway the patient to just 2 more minutes of "You must tell me more about your mother!" Angered at his indifference to her lack of concern about his bowel habits, the patient reached into her desk drawer and pulled out the psychiatrist's semi-automatic weapon, a bushmaster high velocity rifle she kept to fend off both deer and madmen. He ran from the room while the doctor tried to figure out, was this a 45 minute therapy session, or could she have missed a moment of reflection, a tiny little abreaction, something, anything, to get that 52 minutes of therapy to be 53 minutes of add-on psychotherapy.  In the meantime, the patient and the weapon had gotten far from the hospital, and the doctor  realized she had only 5 bullet points on the exam and oddly enough, the review of the pertinent psychiatric system looked identical to the mental status exam.  Ah! She could comment on gait and get one more bullet point: "Patient walked quickly, but steadily, away from my office, bursting into a run, with my bushmaster rifle."  She had enough bullet points on ROS, exam, and past medical, family, and social history to bill a 99213!
    The patient ran and ran, firing rounds of ammunition, all intended to hit tree branches and drop acorns from the sky.  It went well, with the trees raining down an unrelenting supply of acorns until the ammo ran out.  Frustrated, the patient grabbed an axe, hoping his blows might shake more acorns from the tree and keep up the deluge.  An 80 year-old-man, seeing the rifle on the ground picked it up to ask about whether it was obtained at a show or from a store, and if the syphillitic patient was legal and rightful owner, when the patient became agitated, screaming "F*ck the CPT codes, it was a 30 minute session and a 99212 and that bitch is upcoding," and with that he swung as hard as he could for the tree, hoping a few scant acorns still remained to flurry down and pelt his head, when the old man jumped in his way and instead of hitting the tree, the  patient decapitated the old gent.  If only that doc had kept her  guns locked and knew her CPT codes.