mmunity Psychiatrist

Volume 39, Number 1

A fresh view on goals of care- Continued

Success may not result in complete remission of symptoms, smoking cessation, improved cardiac function, and mending of all relationships, but with emphasis on autonomy, beneficence, and non-maleficence, MG may experience an improvement in treatment satisfaction and quality of life as defined by him.

While this paper may illustrate the ideal situation and outcome, there is hope for patients diagnosed with SMI, with or without medical co-morbidities. Elyn Saks not only serves as an example of someone who found a successful treatment regimen that has prevented hospitalization for over three decades, but who has also achieved momentous life goals: graduating Yale Law School, becoming a professor of Law, Psychology, and Psychiatry, and advocating for those with SMI through her Ted Talks and legal aid involvement.11 As Saks wrote, “the humanity we all share is more important than the mental illness we may not.”1 Using autonomy, beneficence, and non-maleficence as the cornerstones of care, the ultimate goal of healthcare providers is to meet patients where they are, allow them to make informed decisions, while acting in their best interest, and to help them obtain as many successes as possible. Providers must adopt a growth mindset, bolster confidence in patients, and get creative about treatment options – the possibilities are endless.

Note: This essay was initially submitted to the AMA Journal of Ethics as part of the 2022 Conley Ethics Essay Contest.

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Spring 2023

Volume 39, Number 1

"Catching" a Malingerer

Amy Gallop, MD Psychiatry Resident St Louis University

During one of my first call shifts as an intern I saw a patient who was requesting psychiatric admission. He said he was suicidal due to being homeless and that his suicidal ideations would improve if he could be admitted to the hospital. He was well known to our service and had presented ten times in the past four months with similar complaints. Following a full interview, I discussed the case with the supervising resident. His suicidal ideations were overall conditional and psychiatric admission did not seem appropriate at this time. My senior resident stated “You caught your first malingerer!” and gave me a hi-five. I smiled. I was gaining the ability to discern people who “truly needed our help” from those who were “gaming the system.” But something did not sit quite right with this new skill.

As a resident, we triage patients in the emergency department. We see first break psychosis, severe depression, delirium, substance use and homelessness. During my training, I have heard the phrase “catching a malingerer” used when a patient is seeking admission in order to gain shelter.

As I have progressed through my training, I have become aware of the flaws in our mental health system, lack of resources for the unhoused and systemic inequities that continue to be perpetuated. The more patients I saw searching for shelter and food, the more I realized our anger and judgement is misplaced. As a resident who supervises call, I do not take pleasure in “catching malingerers.” When I evaluate a person who continues to seek help through the hospital for housing, food and respite, I feel upset at our system.

Why is it more appealing and accessible to be admitted into a psychiatric hospital than a homeless shelter? These people seeking shelter have no other support system or interpersonal connections because if they did, they would be using them instead of presenting to our emergency departments. Our system is flawed. Perpetuating a culture of “catching malingerers” is not going to fix this system and will not make us better physicians.

Spring 2023