Inside Pediatric Emergency Psychiatry with Dr. Megan Schott

Mark Mullen: [00:00:00] Welcome back to Psychiatry Boot Camp. My guest today is Dr. Megan Schott, who is a child and adolescent psychiatrist who works exclusively in pediatric emergency departments. Why am I interviewing Dr. Schott? I have met Dr. Schott at a couple of different conferences, and every time she speaks, she does a lot of academic presenting.

I have been sort of enraptured and wanting to ask her too many follow-ups than would be appropriate in a professional conference setting, so I decided to have her on the podcast. You can look forward to a conversation about the boarding crisis in pediatric emergency departments where children sometimes wait days for an appropriate in-patient psychiatry bed.

We do a session of hot takes from a child and adolescent psychiatrist who is heavily involved in advocacy, sort of what would she change about the world. And we have lots of child and adolescent psychiatry clinical pearls scattered throughout, [00:01:00] ways to build rapport with patients in the pediatric emergency department, and tips for social workers and other staff who interact with these patients.

Dr. Schott, like all of our guests, I will ask you to introduce yourself to our audience. 

Dr. Meghan Schott: Yeah. So I'm, Dr. Megan Schott. I am a child and adolescent psychiatrist, but also cert- certified in adult psychiatry as well. I spent most of my career in emergency psychiatry in various academic settings, and a lot of what I've done is actually build and create emergency psychiatry, especially for children, atmospheres and, places for them to reduce boarding to actually get help immediately from a child psychiatrist, which is pretty much an up-and-coming field in the world of child psychiatry.

10 years ago when I was first looking for jobs, I had to take an adult ED thing because they didn't have anything except for New York, which at that point didn't want to live there. 

Mark Mullen: How common is it to have a child and adolescent psychiatrist actually physically working in the emergency department? 

Dr. Meghan Schott: Not very common.

It's becoming more and more progressive and more and more common as, as we've gotten older. I remember I was interviewing in Denver for a child emergency psychiatrist position like 10 years ago, and they said, [00:02:00] "Well, we don't have anything here. Go to this, like, county hospital and go there." I had asked my fellowship if I could stay on at Northwestern, and create it there.

Like, "Well, we will never have a child psychiatrist in the emergency department." And as of like two years ago, they now have two child psychiatrists running the emergency department. So it's becoming up and coming and it's kind of a great time right now to get involved in it because, you know, you get to actually create things from scratch if you, like to build and create things.

Mark Mullen: Well, I'm glad to hear that it's increasing in popularity to have a child and adolescent psychiatrist readily available for consultation in the emergency department. That brings me hope in terms of our patients accessing expert-level care. Where do you feel like you make the biggest difference for the health system or for the patients as a CAP in the emergency department?

Or another way to ask this question is like, what are some reasons that it's critical to have a psychiatrist readily available for consultation in the pediatric ED? 

Dr. Meghan Schott: Oftentimes even at outside hospitals, they are not even seeing adult psychiatrists, so it's being staffed by social workers. And I have found that social workers have a hard time making the hard decisions.[00:03:00] 

and so what we really see is like about a 50% of kids coming in are slated for admission. But when you actually have a trained child psychiatrist who like that is their job, not just during CL and it gets tagged onto emergency, we actually see that rate number of orders drop from 50% of people presenting to almost like turn of the day 15 to 30%, which is a substantial drop, especially like at one of my institutions where we were getting like 15, 20 consults a day 

Mark Mullen: So when you say the number of boarders go down, could you unpack that for me?

Maybe define a boarder and what you mean? 

Dr. Meghan Schott: So that is a loaded question in itself. so depending on who- whose definitions you're using, and that also changes with CMS's def- definition, in order to actually be considered boarding, they need to be in the emergency department after the decision is made or on a floor for at least eight hours after the decision is made what's happening, and that's how it technically counts as a boarder.

US News and World Report, CMS, all these other, like, big agencies are, like, kind of changing what that means and they-- and what that means for each place because some places are, like, boarding on, like... I've worked in multiple places, they board them in the emergency [00:04:00] department, take up emergency beds. But some people will board them on the medical floor, and then they're wasting good medical beds.

So it becomes a catch-22. What is your hospital willing to lose money on? An emergency department not having space there or on a medical floor where you can't actually do those interventions that really need to be done for medical patients instead of psychiatry patients? 

Mark Mullen: So these are patients where someone, either a social worker in most cases it sounds like, child and adolescent psychiatrist, maybe the ED doc has recommended psychiatric admission for a patient, but the patient is not immediately able to be transferred.

So you're saying they either remain in the ED, sometimes they go to the medical floor. Why can't they just be transferred directly to the psychiatry unit? 

Dr. Meghan Schott: There are not enough beds. And this is even for adults, although it's not as prominent as adults. But in the adult world, they got rid of a lot of state hospitals and, so it really kind of made a lot of chronic mental illness.

People come into the ER. For child, you don't get a lot of money for child, and it takes double amount of time. And so who wants to create more psych beds for children when you're not gonna get reimbursed back the same rate you want? And psychiatry in general is, like, the least part of their totem pole [00:05:00] in terms of like, "Well, I get a lot of money from surgery," the hospital does.

"So we're not gonna, like, really emphasize psych." But they probably should emphasize a little bit more psychiatry because if we're taking up beds where they can't get space... And we also know if you actually have better mental health, you'll have reduced emergency visits and, reduced, like, surgical times and all these other things.

It could improve whenever your mental health is improved, so we need to be looking out for everybody. But there's substantially less beds available for kids, and some states, like, have zero beds and they're coming, at least where I'm at in Utah, from, like, really far north Montana. And you're like, "Cool.

That's really far." And then half the time when I'm listening to the story, I'm like, "If I had seen you, I could just-- wouldn't even have you be admitted." But, like, I'm at a different hospital and now you're gonna travel eight hours just to get to your nearest hospital while you're sitting in their ER for a long time.

Mark Mullen: Wow. So are these patients you're saying that have been seen and, evaluated in Montana and then transferred to you? Transferred to your emergency department? 

Dr. Meghan Schott: sort of, sometimes not. Sometimes it's the floor. we, since I now work through, like University of Utah is where I work re- currently my paycheck, but my [00:06:00] hospital system's Intermountain.

The Intermountain system will take anyone that's in Intermountain. They... And they span multiple states, and so those could be transferred to our ED to the observation area where I can make a decision. But it also seems silly. I'm like, "I'm gonna discharge you probably when you get here. Why I'm gonna wait, make you wait eight hours?

And if that's what you really think they need, maybe it's better to wait for a bed in your ER if that's what everyone e- else there thinks," when I already know kind of what I'm gonna do from the 

Mark Mullen: case 

Dr. Meghan Schott: presentation. Wow. 

Mark Mullen: So a patient might get transferred to you from eight hours away to be evaluated in your obs area by a psychiatrist, by you, and you may decide then the patient doesn't need to be admitted and ship them back eight hours where they came from?

Dr. Meghan Schott: Yeah, sometimes I try not to be that mean to parents, but it's like, what is... But then I'm kind of being mean to our staff on the inpatient floor who now have to do that stuff too. 

Mark Mullen: Yeah, no, and I should apologize for my tone. I, totally understand where you're coming from. I, don't mean it as it's mean for parents.

It's just such a frustrating system to navigate for all of us, including you, right? Like, you're having to make really difficult decisions, and, how far away they live from the hospital I don't think is a factor that [00:07:00] ideally should weigh into our medical decision-making. Certainly in medical school and residency, I was never taught how to weight that, like in a suicide risk assessment, for example.

But I also can see the practical side where it kind of has to. I mean, the, the parents have driven eight, eight hours for their patient to be-- for their child to be admitted to the psychiatric hospital, and you might say they, they don't require admission. I'm gonna follow up on that. So you had mentioned earlier that a lot of times Because there are not CAPs available in emergency departments, social workers often filling this role.

And we have a lot of listeners that are social workers. I'm constantly hearing from social workers that say they really appreciate hearing this sort of medical professional level education because they don't have much exposure to it in their own training. And on-- for my part, I often tell my patients that the closest thing that they have to an angel is their social worker.

So it's, definitely a mutual admiration society. But you mentioned that you feel like it's difficult for licensed clinical social workers to make these decisions. Why do you think it's [00:08:00] difficult for them to make the, quote-unquote, "hard decisions"? And what do you mean by that when you say hard decisions?

Dr. Meghan Schott: No, I, wanna preempt this. I've had amazing social workers who will have a hard conversation, but I find, as a whole, it's not even that it's a hard decision. Like some even for-profit hospitals do the same thing. You say you're suicidal, even as passive, that guarantees you an admission because they don't want the liability.

Adult psychiatrists do this. Like, it's not just social workers. You know, social workers' training is, not as in-depth as psychiatrists' training. And they-- So what I also find that they'll understand what an inpatient unit can and can't do, and that inpatient units are not benign. There's a lot of problems with inpatient units, and they're not-- They're looking at maybe what they're saying, which, yeah, I can probably get them to be a bed from what they're saying.

But if I look at the entire social history or what else is going on, in-inpatient admission might be the worst decision to make, especially if it's-- For other reasons, it could be like, "Hey, you can't get into military and stuff when you get older because you have, like, an inpatient psych admission." So you look at that.

You look at, like, what is the social capabilities of the family, social capabilities of the health [00:09:00] system in general. You're looking at things that are just really hard to, like, put on paper why this is not the right fit or the right thing. sometimes kids missing a week of school or however long it'll be could be very detrimental from a social impact standpoint, or maybe they're struggling academically, and now they still have to pick, it up and do those things.

And then even though it's supposed to be confidential Oftentimes the school will know what you're there for, and depending on the school district, can actually be very retaliatory upon the family itself. Or, like, maybe their life is all football, which I've had a couple of times, and they're gonna m- miss the state playoffs and then, and they won't get a scholarship that way 'cause they didn't see them in the state playoffs.

So there's a whole bunch of things that are not just, like, black and white, that we gotta kind of take into account as a whole person rather than just, like, a sliver of what they're seeing right here, right now. 

Mark Mullen: Yeah, I hear you. So there are real risks to psychiatric hospitalization. We've discussed some of those risks in adults, but you mentioned things that have never occurred to me that are specific risks for children, pulling them out of their support system.

That was a, that was quite the laundry list. That really kind of opened my eyes to how this looks differently [00:10:00] in children. And regarding the difficult decisions that need to be made, I appreciate your point that the training is different in terms of the exposure to these inpatient psych units and what happens there.

And I think that... Well, for me, I did two months of child inpatient psychiatry and residency, and it really did open my eyes up to how much of these-- how many of these problems are social problems, how many of these situations are children trying to control things that are outside of their control. They should be in safe environments.

They should be in environments where they can have an impact on the world around them, but they're often not. And often the only card they sort of have to play to be taken seriously is threatening their own life or hurting other people. So I do appreciate that those are problems that may or may not be solvable through an inpatient psychiatric admission.

And then you also have to look at the resources, right? There are also children who have severe and persistent mental illness who really do need acute stabilization by a physician. How bad is this where you are? How long are these [00:11:00] patients waiting to get a bed? Could you paint a picture for me? 

Dr. Meghan Schott: So in Utah, we have like all the services which I'd never experienced when I was living in Washington DC at the children's hospital there.

So I can get them into residential. I can get-- Well, maybe not me in residential, but I... they can get into residential usually fairly quickly compared to other places. They have PHPs or day treatments, depending on what word you use, and so the outpatient program. And in additional to like traditional outpatient programs they might have.

Other places I worked, we didn't have access to those, like inpatient or outpatient, those are your choices, right? And which one's going to be the better fit. So people-- Back to your question of how long are people waiting here in Utah, depending on what the thing is, it could be up to like forty-eight hours in, in our m- observation area.

We try to say, "Hey, it's only for twenty-four." But oftentimes it's a lot longer because, especially if, notoriously they have aggression or autism. Those are things that are notoriously across the entire nation are going to stay longer because people don't have enough staff support or something else to maintain them in a inpatient unit.

Mark Mullen: Yes. The aggression, the autism is definitely something that I've seen as well. So let's get into that a little bit. Let's [00:12:00] say you're a pediatrician listening to this or you're working at a children's hospital and these are patients that are going through a really difficult time and certainly suffering deeply and also are really challenging for the system, for the people working with these patients, putting themselves at risk and also wondering, "Is what I'm doing even helpful?"

Do you have any particular tips for working with this population? And maybe another way to think about this would be, is there anything that you see done commonly that you think is a major mistake that we, need to make sure we're not doing with these patients? 

Dr. Meghan Schott: This doesn't quite answer your question.

The biggest people that bring people into the hospital are police and schools And depending on where you're living, we don't actually have good connections to either one to tell them like why this isn't a good fit, why this isn't a good fit, what you can do here. And police bring them in for aggression things.

You know, they choked out their mom or something, and I'm like, the mom doesn't want to come home, but n- they got choked out their mom because they didn't get their cellphone. Like, what am I gonna treat an inpatient unit for? And I'm not saying kids should go to jail, but like police will bring them back to us, [00:13:00] and I'm like, "Cool.

Now I'm gonna have a pissed off mom as they bring them back, you know, like two hours later." Like, I can't fix this. They're calm now. You know, en- enjoy getting choked out by your, 17-year-old son or daughter for not getting their phone. So it becomes this weird, like catch-22 of like how do we make sure we have those connections?

We're not wasting people's time or energy or money or whatever and getting them the appropriate services sooner rather than later. I feel like a lot of these things can be mitigated if you have like an urgent care center as opposed to an emergency department for s- mental health, and that's an up-and-coming thing that's happening.

So you just go there. School sends you, you can't go back to school unless you get clearance. Cool. Checked off the box and you're cleared. Now you can go instead of boarding up, staying and boarding and taking up space in the emergency department, which don't-- Urgent care centers go much, faster than emergency departments because of how everything else they gotta do to make sure you're medically cleared and how many people are just waiting in there.

And so if you're able to set up an urgent care center where these less intense cases need to go, it might be a lot better to help save money for your, institution as a whole. 

Mark Mullen: So in [00:14:00] terms of solutions to this ED boarding crisis, specifically for the CAP population for children, I'm hearing a few things from you.

I'm hearing, one, making sure that we are recommending psychiatric admission in cases where psychiatric admission is genuinely indicated, and we're not just recommending psychiatric admission because I guess we're afraid of getting sued or it feels like what someone, for example, the parents want and so we just do it as a knee-jerk reaction, right?

It's a medical intervention with risks and benefits, and so we need to think really carefully about those risks. I love that you mentioned the urgent care situation, you know, creating levels of care that are not strictly inpatient psychiatry or home. I think that we could add residential treatment centers to that, having a place for the patient to spend some time, you know, in these situations where it's not something that's going to resolve over three to five days and it might need to be patterns of behavior that are learned over like one to three months, say You mentioned community partnerships, educating first [00:15:00] responders about what cases are appropriate to even be assessed in the hospital.

What else am I missing in terms of potential solutions to this ED boarding crisis? 

Dr. Meghan Schott: So a lot of counties, states, I don't know, have, mobile crisis teams. Like, those are, have been traditionally more for adults, but more and more they're getting more funding in children too. So they call this line instead of just bringing them straight to the ER.

So a social worker can go out to their house, at least tell you, "Yeah, don't waste time coming to the ER," right? And that's, oftentimes unfortunately funded by state resources, and once those resources die, then I don't know what's gonna happen. But those resources also prevent things from coming into a hospital as well, where they call this, kinda get their opinion, can set up appointments, can do everything else that an ER can do, but they're still, like, in the comfort of their home, not coming and getting a huge bill, a medical bill.

Mark Mullen: Yeah, that's a win-win for everybody. They can be treated in their environment, they can save some money, and we can relieve the ED boarding crisis. So that's that sort of case management model. It sounds very similar to ACT teams, Assertive Community Treatment teams in adults. 

Dr. Meghan Schott: Yeah. Well, so [00:16:00] it... I mean, but so for ACT teams are, you know, geared for, like, someone who has chronic SMI stuff, right?

Where these are actually like, "Hey- You-- like you as an adult can call and be like, "Hey," like instead of calling 911, you're gonna call this mobile r-response team and say, "Hey, my son just said they're suicidal. What do I do?" Okay, let's go, depending what-- how bad it is, they'll-- they're gonna do a pre-assessment on the phone to say like, "Oh, no, that kid needs to go to the hospital.

They overdosed," right? "You didn't tell me that." Versus like, "Eh, they say it all the time when they get mad. Let's send this mobile crisis person out to actually do that." So they're not quite the same thing 'cause the mobile crisis teams are responding to crisis, and it could be like any crisis. You can go there because, your kid's anxious becau- and like freaking out 'cause their cat's up a tree, you know?

Like very broad things that ACT teams won't necessarily have. 

Mark Mullen: Beautiful. Now, in talking about these response teams, is this like talking about carbon capture as a solution to global warming? Meaning we're talking about something that would be nice but sort of doesn't exist very much yet? Or are these response teams actually out in the community?

Like how common are they? 

Dr. Meghan Schott: They, are actually [00:17:00] out in the c- out in the community, at least in most places I've worked at. Now, finding one that's specific for child's a little different. They're not always there, which is why they partnered with pediatrician's office and done like access. You know, where you just talk to the pediatrician like for basic simple things.

They don't have psychiatrists to go around. It's kind of like that in the same way where they're-- in most states, not all, have like access programs where they can call and get advice from psychiatrists. I have not worked in a state that didn't have some form of mobile crisis. They might not just be child, adolescent specifically.

Mark Mullen: Okay. I'm gonna tell you about-- This conversation's just kind of reminding me of one of definitely top five most difficult patient encounters that I had when I was in residency. And I am gonna ask you to treat me like your resident as if I was in supervision and sort of kinda help me process maybe how I felt about this and how you feel like it could've been handled best.

So I'll, I'll-- obviously, I'll change some patient details. This was a 17-year-old female who had a pretty clearly established diagnosis of conduct disorder, like [00:18:00] longitudinally speaking. in fact, the patient herself even sort of said like, "Yeah, reading these criteria, this is definitely me." And the situation was that the patient had, I believe, chased a loved one around the house with a knife and then was brought to the hospital by the police.

We did not recommend psychiatric admission because this was not the first time something like this had happened, and she'd been admitted many times in the past, and we just didn't see a role for psychiatric admission. And so I was kind of explaining this to the patient and her guardian And it was a really difficult conversation because I kind of, I explained all this in detail sort of academically, and the patient said, "Okay, but then, like, how do I get help?"

Right? "So okay, so, so let's say I do have conduct disorder. What then?" You know? And I don't... I just didn't know what to say. I, I d- 'Cause I'm not familiar with many particularly good therapies there. I feel like a lot had been tried for this patient, and I was just sitting left, like I was the [00:19:00] gatekeeper to the, inpatient unit, and I was denying the patient, and she was saying, "So then what?"

And I, just didn't know how to sit with it. What, what advice would you have for me navigate an encounter like that? And feel free to say, "Hey, Mark, you just did that wrong." You know? I, wouldn't have done anything like that. 

Dr. Meghan Schott: I actually think you did things right. I don't think you did anything wrong. I don't know the correct answer for that.

Our healthcare system is broken, right? The gold standard for treating this kind of kid is multi- multi-systemic therapy. I don't know any state that actually has that, but that was on my board exam, the, my tenure board exam I just took last week, and like, I know that's the right answer. Can I actually get it?

So, like, depending on, like, you know, how bad their conduct stuff is, do you need to lean more into the jail situation? And I'm not saying jail, but they, you know, if they are doing things and actually attacking people, in a jail setting, they, or a prison setting, I don't know which one it is, for-- They do actually provide psychiatric care, you know, detention centers or something.

I'm not advocating for that. I'm just saying that is a, something that, where they would get treatment. If this is chronic, you know, do we need to look at residential programs, right? Where I was in DC, took nine months to get [00:20:00] any type of traction to maybe apply to a residential, and they didn't have anything in the area.

So you're looking about a good 18 months before you're getting any true help. One of the things that I do to kind of-- I, feel like I do a lot of bad things in the emergency department, and it's probably 'cause our system's broken. Like, we don't have a good system. But I'm doing what I believe is the right thing at, with what the system, with our broken system that we have.

And so kind of how I reconcile it to myself is by advocating on a local level to figure out how we can maybe get some more funding for those services that we're talking about, how we can actually change the landscape, not close all our psych hospitals, how we can actually have one that maybe is specific to conduct disorder.

So even though that change is very slow and tedi- tedious, like, putting your voice out there allows me to feel like I'm doing something productive as something else. And I think you as a resident, I'd wanna know why did that bother you? Did you think your response was the wrong response, right? If it's not, okay, then let's see how can we fix it now and/or in the future.

And figuring out, like, kind of in the emergency depart- department in [00:21:00] particular- What is your, why in a sense for how to make this better or how you, how do you want it to look? And also, I always say be upfront and honest, right? I mean, I think the best thing we always talk about with anyone is people can read your bluff through and through, and if you're not honest, you're, like, trying to do something that's not you, they're gonna railroad you.

A lot of the people will. Like, so I think being honest, saying, "You know what? You're right. This sucks. I don't know what can treat you either," right? Like, "What do you think you need?" You know? So it's often just like inpatient's off the table, but what do you need? And maybe it's like, "You know, I'd be so much better if I had a new refrigerator."

"Cool, social worker, we'll get your case managed. I'll get you-- see if your mom can get a refrigerator." Oh, you need ga- Like, I've, done refrigerators and, like, gas lines and things like that before to help the social s- situation be better. But figuring out, like, what small thing you can actually make in that person's life that might make a big difference.

I took this joy in work class, and they called them pebbles, for the small things. The small things can actually reduce a lot of stress and anxiety, reduce all [00:22:00] these other things with, yourself and with the family, and how do we act- or, the patient family. So how do we actually get rid of some of those small pebbles that might make it easier?

Mark Mullen: That's beautiful. Thank you. I feel much better having aired that out with you. It also makes me feel like I'm doing an okay job as a supervisor myself because I feel like a lot of times in supervision, the answer is like, "Yo, the system is really messed up." The system does not work. The system forgets about our patients.

The system is not built for people like the people that we're trying to help, and we are operating in some really terrible circumstances a lot of the time. So I appreciate that you kind of centered me there. And then I'll parlay this into a, a pearl that I-- This is, like, one of the things that I hope that every medical student or resident that rotates through my consultation service learns, which is how to conduct a meeting with a family, and you sort of said this there.

My number one tip for this-- There's mnemonics. There's the SPIKES mnemonic. There's all these mnemonics. But my, my number one tip is let the other person lead. [00:23:00] listen, and then you can talk. And you talk very honestly and vulnerably because a huge part of that, you know, when you mentioned, like, "Okay, I'm gonna give you my honest opinion.

I'm gonna give you honestly what I can and cannot offer. But then I'm gonna turn it over to you," or ideally, I've already heard from you about kind of what you're expecting, what your concerns are, so that we're not talking past each other and I can directly address whatever's on your mind. Dr. Schott, we're gonna go to break and when we get back, we are gonna talk about hot takes from a child and adolescent psychiatrist.

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Welcome back to Psychiatry Boot Camp. Dr. Shah, I'm gonna do the most evil thing that an interviewer can do to a guest, and I'm gonna quote you back to you. So in an interview with the American Medical Association, you were talking about what it was like when you started practicing pediatric emergency psychiatry at Children's National in Washington, D.C.

And you said that people were upset with you because you were changing who was and wasn't being admitted to the inpatient psychiatry unit in an effort to help the ED boarding crisis. Could you go into detail about what these changes were and how they were received? 

Dr. Meghan Schott: Yeah. So one of the biggest thing that happened, which actually was-- is terrible, but also ended up being a good thing, we were having our child protective services team just dropping kids off and giving them a respite, right?

And I'm not saying these kids weren't aggressive and everything else, but like one of, one of the kids was like, they have a huge reactive attachment disorder, they have huge trauma stuff, and their foster care was going to be changed. [00:27:00] And they told him, and he flipped out. You know, I've been like, "Well, no shit, he flipped out because he doesn't want change."

It's working against his ethos and creating more trauma for him, even with microtrauma, and creating that attachment issues that he's been having. So we were-- I was basically saying, "No, he can't be admitted. This is who he is. Like, that's not gonna change 'cause you changed his location. It's gonna be the same thing two years from now or, you know, thirty minutes from now or the exact same thing if you're doing something that's really perceived that way."

And for the most part, Child Protective Services there in D.C. was not happy with me and what I was doing. And finally, they used-- It's one of my favorite kids that I've ever treated. They finally took somebody into custody, and he kept doing not so good things like stealing water guns, he's like eight or nine, from the store.

And I told-- warned them before they take him away from his parent, "You need to make sure you get him a place that's actually going to be able to sustain this level of, not necessarily aggression, but like independence, autonomy stuff." And they took him out without being prepared. And they started using us like every week.

And finally, my, my boss was like, "Just admit him. Just admit him. He's here [00:28:00] now." But they actually dropped him off, told him he, he didn't actually do anything this time, told him they were just gonna get paperwork And then he'd be gone. We're like, "Oh, we are not admitting you now. Like, you don't even have a reason to be here."

And so the kid kept crying and about that. The good thing that came out of that case is Child Protection Services was like, "Well, come visit our office at centers. That way you understand what's happening." So I now will have on a first-name basis with the highest level, and this, and a lot of other people too that are high up in Child Protection Services.

I had their emails. I had now seen their site and was able to do that. And one of the questions they actually asked during our site visit was, "Well, what do we do when we don't like what your psychiatrist is recommending?" And we were just like, it wasn't even me who said it, but it was one of our nursing leaders who was also there from the emergency department says, "Nothing.

You guys don't work here." 

Mark Mullen: Right. 

Dr. Meghan Schott: You can talk, to her and, or him or whoever it is, and, you know, address it with your concerns with them. But ultimately it is, you don't work here, and it's your, our psychiatrist's decision, not yours. And with that, we were able to build more of a [00:29:00] relationship, so they would actually, if they're gonna have someone stay there for extended period of time in their emergency department, and by extended, more than 24 hours, they had to provide staff.

And so even if, like, almost as a one-to-one, although we can't treat them as, like, a one-to-one staff, but they had to provide staff 24/7 on cases they were gonna do that. We'll, provide housing and shelter, and I guess food, but it's still, you're providing something to keep your skin in the game. And so indirectly, it ended up being a good thing by being...

It forced other people to, like, come to the table with us. 

Mark Mullen: A, a really challenging case that sort of laid everything bare and said, "Okay, this is where we're at, and this is our position. This is your position." And then once you kind of had that radical acceptance of what's so difficult about it, you can start to think about what can we do that's productive.

I also, I mean, look That is such a burnout-inducing experience. The moral injury involved with turning, you know, with even just dealing with this individual who's eight or nine years old and clearly just deserves a better quality of life, period. And especially ma- being made to feel [00:30:00] like the bad guy by CPS who says, "Well, why can't you just fix it?

You know, why can't you just admit them and fix it?" I, I-- that's, that would be a horrible emotional experience to have to go through. I think it's really awesome and deserves a shout-out that your administration was supportive because I truly-- I, I would have to leave that job if I was being forced to make those difficult decisions and my administration was not supportive.

So I'm sure that meant a lot to you that your admin kinda got in there with you and said, "Look, this is our position. This is our responsibility as a hospital system." And then the kind of connotation there is, and then let's think about what your responsibility is to this individual because it's interesting.

I-I'm thinking about the listener experience on this episode. And we mentioned basically incarceration or involving the justice system as one vehicle for dealing with these really difficult patients and situations, and then about five minutes later, you are taking a very trauma-informed lens and talking about microtraumas even.

And [00:31:00] so the question might be, like, who-- which side are you on, you know? And it-- that's a very, black or white way of thinking about this that psychiatrists would kind of immediately recognize and reject. But I do think it's the way that a lot of the general public are thinking about these issues.

Certainly, it's the way that CPS was thinking about this when they were saying, "Why doesn't your psychiatrist just do a better job?" And I think the truth is that these issues are, totally unsolvable. If they were solvable, they would be solved by now And this is why I kinda hate that psychiatry became as on social media because you cannot have this conversation in 30 to 60-second shorts.

Like, you have to be able to hold in your mind that this person deserves better. This is a, an attachment style. This is a reaction to trauma. This is not the eight or nine-year-old's fault. And we have to do what we think is best for this patient, what we think is best for society. And I think where I'm going with this is there are different institutions in psychia- in society who have different roles, and the role of psychiatry is to treat medical [00:32:00] problems and help in- increase people's quality of lives.

And I think we're often forced into this sort of like just make everything better or even a public safety role, like if you think about the Tarasoff doctrine and all that especially. And I like that you're kinda firmly saying, "No, my role as a psychiatrist is to be a healer and to help people when I can.

And also part of that is to be a steward of these very finite resources which are in, great demand." And then we need to look at our other partners in society and say, "A- and what's your role? You know, why do you exist? What does society charge you with?" Because it's just not up to psychiatry to solve all these problems.

Dr. Meghan Schott: Yeah, and it's not up to, like, the police or anybody else either. I mean, one of the things that I did with-- in the advocacy world in DC, it's just luck of the draw. But right after George Floyd happened, I was already... I'm not sure which one happened first, but I was asked to speak to government officials about the boarding crisis and about how police were bringing them into the hospital, and I'm actually now a named witness on, the ACLU on how DC actually has been messing with mental health patients too as a whole.

And it's been an [00:33:00] interesting journey to kind of make those changes. But with the George Floyd thing, because of that, they heard me on the podcast, like less than a month later, a white paper was produced from that same thing, and then less than a month from there, they're-- they were doing a trial of sending social workers whenever a 911 call was getting placed from-- that was mental health in origin, that way it wasn't just police responding.

Because that isn't their wheelhouse. That isn't what they know. And, you know, social workers can maybe not be as scary, even if they are with police, to actually help tone down what's happening instead of it just being this really adversary kind of thing, which oftentimes, unfortunately is what the police get from their, background or image 

Mark Mullen: Oh, the other side note that I'll make before launching into the hot takes is if any listeners are wondering why we spent a couple episodes talking about competency to stand trial wait times in Missouri and nationally, it's because that is so burnout-inducing for me, that's sort of my advocacy is I, cannot see these patients day in and day out and see the state fail them so egregiously and not use my platform to say something because I just wouldn't be able to sleep at night.

So I [00:34:00] appreciate the audience's patience with that one. All right, let's get into the CAP hot takes. I'm just gonna start out of the gate. This is a big one. As a child and adolescent psychiatrist, if you could change one law, either in the state of Utah or nationally, what would it be? 

Dr. Meghan Schott: Oh, we need parity.

Even though it's like, okay, so healthcare parity in general has-- And this is a national thing. They gave it, us parity with, with I think O- with Obama with the new-- with that being like, "Hey, we're gonna get paid the same." But still, really wasn't happening at all. I, was still getting insurances that were like, we're not covering inpatient mental health at all."

Even though you're using the same code as a pediatrician from like the nine, whatever the billing codes are, if it's, your primary diagnosis is psychiatry, we're not gonna reimburse you as much Well, executive order went out, that's been a long time standing kind of thing. Executive order went out, one of Trump's executive orders being like, "We're not going to enforce parity."

Now, so far we haven't seen a backdrop, that I can notice, in not providing parity after they said they're not gonna enforce it, but they weren't enforcing it to begin with. So if we were able to actually get paid for the time and services that we were [00:35:00] rendering, it'd be lovely and not to be treated as second- secondary.

You know, our, expertise is still our expertise. You don't see other providers or other disciplines doing their own admits and calling in the insurance companies. I know how to do that. I've done it with my entire career, but there's no way you'd have a, psychia- there's no way you'd pay a surgeon to be doing that.

No, you must get that, and they expect psychiatry to be able to do that and wondering why we don't have enough money, and part of it's because they want that done before they can even be admitted, which is another sign of not having affordability and parity in that world. You can't just admit them just because.

You have to go through some other one else saying, "We agree with your admission." I 

Mark Mullen: appreciate the robust answer to that one, and you kinda even got into the difference between a law, right? With the Affordable Care Act, we theoretically do have parity, and then the way a law's enacted, and that gets into kind of the executive orders and how each administration interprets it.

So parity is a really good answer to that question, increasing access for our patients. I'm really excited about this next one, and we're just gonna indulge in some black or white thinking here, right? We're just gonna say, just for funsies, we're gonna throw dialectics [00:36:00] out the window for this one. 

Dr. Meghan Schott: Okay. 

Mark Mullen: If you could remove one app from existence as a child and adolescent psychiatrist, what would it be and why?

Dr. Meghan Schott: It has to be specific? Well, I did read this question, and I was th- thinking Discord originally. Like, but a lot of the social media platforms in general have been very detrimental. But Discord, I've seen the weirdest things happening with Discord that I just was like, "What?" I... Like, the first time I even heard of it, I was like, "They're allowing you to do what?"

But social media in general has, it's been a, a huge problem. We used to be able to escape bullying. It only happened in the schoolyard, and that would mainly be with males. But now that we have social media platforms, it's actually, you can't escape it. It's there 24/7, and it's b- it's influencing more females in that realm rather than males.

And so it becomes nonstop bullying, nonstop whatever, and you can't get rid of it. So I mean, social media in general, but Discord is where I found the most weird things. Discord. 

Mark Mullen: So y- kids are, like, hanging out on Discord now? Oh, yeah. Like, middle schooler, that's, like, the spot. 

Dr. Meghan Schott: I mean, I don't know if it's the spot, but like, and to be fair, I found out about it five years ago, [00:37:00] but people are still on Discord, for sure.

Mark Mullen: Okay. Good answer. So I am gonna ask you for, like, a specific example here, just so that people kind of know what you mean when you say that these are-- can be dangerous spaces for kids. 

Dr. Meghan Schott: So, I've seen social media platforms in general be places that you can't really know who you're truly talking to.

And so with that, I've seen, elements of sex trafficking, and DC and Houston are the two primary places that it happens, but it can happen anywhere in the United States, and you gotta learn-- have to figure out which-- what are some signals for that. I've also seen a lot of people will be posting nudes on these websites-- on some of these websites thinking that they, oh, even Snapchat, thinking they can't, like, block it.

But people will save them, and now you're-- especially with a child, they're now in danger of, like, child porn. I've seen numerous cases of both of these things that are kind of scary, and how do you get out of that? And then it becomes a legal matter, and then who's in trouble? Is it you for giving it to the person?

Is it the person distributing it? A whole bunch of issues that come along with that. 

Mark Mullen: Right. Yeah. Actually, on both sides of that coin then, both people are at risk kind [00:38:00] of in, in quite different ways. And I, think when I hear this topic covered, I feel like the bottom line is always, as a parent or a trusted adult, making sure that your child knows that if they get into hot water with something like this, y-you are always a safe person to come to help them navigate this.

And not reacting with a, "How could you do this? You're going to hell," right? But reacting with a, "I am so grateful that in your moment of need, you would choose me to help you navigate this, and let's get it worked out." Thanks for biting that off. That was a really real answer, so I, really appreciate it. next hot take: Children in crisis don't always show up to ERs that are staffed with child psychiatrists, so what is your advice to ER staff who encounter these patients in community hospitals that, let's say there's a multi-hour drive to the next pediatric ER, or let's say there's a multi-hour drive to an inpatient child and adolescent psychiatrist.

What's your advice to ER staff for dealing with these patients? 

Dr. Meghan Schott: I don't know. It depends on the resources of the hospital, but in an ideal world, you don't want them being next [00:39:00] to a psychotic adult or someone-- in an ideal world, you'd also don't want a curtain dividing between the thing for a social worker or whoever it is can do their assessment because you're gonna be asking a lot of personal questions.

And so those combinations can actually be very not helpful for the interview if they don't have a private room or a private place to interview, even if it's not the room itself is private because-- or if they become aggressive, and they need to be strapped down, you're like now into this other person's space.

So I think really just making sure that, like, even though it's taking up a resource, if we can get them into a more space that's healthy for them, both for-- and for the interview, it'd be very helpful to make sure we're actually providing care in a way we can get a proper assessment, at least as proper as we can, to make sure we're not scaring them.

'Cause that's often the first place they will encounter mental health is not a child psychiatrist. It's either your pediatrician or in regular ER, and you wanna make sure that those-- you're not, like, alienating them from psychiatry as a whole in the long run. 

Mark Mullen: Right. The first time they come to really seek help, they are next to a psychotic adult that all this is going on.

And so now they and [00:40:00] their, parents have said, "Okay, well, I guess that's not gonna be the solution to our mental health problems." And so then you don't know what comes next. I love that. I wanna talk about a situation that probably comes up for you every now and then and kind of your tips on handling it.

Again, maybe if you're talking to a resident, how you would encourage them to handle this. So if you have an adolescent, you know, a fourteen to sixteen-year-old patient and a parent, and the two of them want different things in terms of the treatment plan, do you have any go-to tips on how to navigate that relationship?

Dr. Meghan Schott: Well, my first question is, what do you want as a resident? 'Cause sometimes, like, what I get from a lot of residents saying, "Well, the parents want this, the child wants that." Okay You're the expert here. What do you want as a resident? What do you think is the right thing to do? And then afterwards, depending on whose side you're siding on, but, like, if you were siding on the parents' side and not the child's side of something, I tell them to blame me as the psychiatrist- Love that

not the parent. that way you can place all the blame on me, so hopefully... And then you can hate me as long as you want, but don't hate your parent. when [00:41:00] you're siding with a child, I will-- depending on what the reason is why we're siding with the child, but oftentimes I will use-- u-up play or downplay their own emotions in the parent to get them what I think they need.

Like, if they-- I up play emotions when they are being nonchalant about their child overdosing and, like, they're going to miss their cheer camp. And be like, "Okay, missing cheer camp one day versus, you know, your child your entire life, very different." And yes, it sucks, but I'm afraid your child's gonna go someplace, and could you live with yourself for doing that if something happens, right?

So I, play up a lot of the emotional side, depending on what it's for parents. 

Mark Mullen: Beautiful. I feel like if I was your resident, I would feel very, reassured hearing that advice. And I gave a grand rounds to our maternal fetal medicine, department recently, and I kind of reviewed some of the decisional capacity guidelines to do that.

And I was really interested. There, there's a kind of an ethical position that I think is standard of care, especially in MFM, where when you are counseling a patient for a decision, the degree to which [00:42:00] you are directive versus just sort of evocative in what the patient wants is directly proportional to the risks associated with making such a decision, right?

So, like, if you have in, the case of MFM, triplets that are all breech and the patient really needs a C-section, and they are demanding a trial of vaginal birth You might be very directive and just say, "You know, a- as your doctor, the risks are too high. I just can't offer that intervention, and this is really my recommendation."

Versus if it's, if it's kind of a soft call, you might kind of offer both options. So it helps me feel like as the doctor, I don't need to just be this sort of server. Like I al- I always do try to serve my patients and I ask myself a- at every visit, how can I wash this patient's feet? That's kind of my razor of like, did I serve this patient the best I could and remove myself from the equation?

And often it is by saying, make me, the guy in the white coat, the bad guy. I think that's a really effective way to serve your patient. But if you get too far into that mindset of serving, you forget that you're the expert [00:43:00] and that you have a lot of training in this, and you've seen this before. And a lot of times the other-- the patient hasn't, and they come to you for your expertise.

So it is okay to be directive. It is okay to offer a third option. It is okay to pursue what you think is best. I think that is a really good way to counsel a resident on that. 

Dr. Meghan Schott: When you were saying something, like something caught in my head, I'm like, "Oh, that actually..." What I always say is, "I'm the expert in psychiatry.

You're the expert in your child," or, "You're the expert in you. And together we're gonna put our expertise together to find the right plan." We also know in general that, people do better with choices. So even if you take one off the table, you're like, "This is definitely not gonna happen. But if you want outpatient or intensive outpatient, I don't care.

Choose which one, which of these two poisons do you want," right? And to remember yourself not to... Like I, I think a lot of the things we learn in kindergarten, like still hold, up. Like we know you, you'll do better with choices rather than being 100% directive 

Mark Mullen: Yeah, exactly. If you feel like you have authority and agency over a situation, you're gonna be a lot more involved in your own treatment plan.

Dr. Shah, we've covered a lot of territory. Do you have any final thoughts for our listeners? 

Dr. Meghan Schott: [00:44:00] Not everyone can do emergency psychiatry. It's a very hard job and with very little to no reward, and you need more of that direct personality in order to do those-- to make these hard decisions. I like to boundary cross slightly in the sense that, like, I'm okay with sharing some things, not sharing other things, but making sure why you're sharing something.

Is it for you or is it for the patient? And I say that 'cause I often will disclose that I have ADHD to my patients, not always, depending on what it is, because some parents actually feel like ADHD is a death sentence and their child won't go anywhere. And so then I'm like, "Well, do you think-- I have ADHD.

Do you think being, a doctor is not a bad thing, or you think it's a good thing?" Right? So sometimes I will self-disclose in those kinds of things and think about if it was right-- who I did it for later, is very helpful for me to make sure I'm not fully boundary crossing. 

Mark Mullen: I love that, and I think all of us have probably, when we've reflected on it later, said, "Yeah, that was for me.

That was to make me feel better in the situation for any number of a million reasons." And I think with [00:45:00] time and supervision, we get better at deciding when to self-disclose. I also love that you have to kinda tailor your practice to your personality. I don't share this with patients because everybody hates referees, but I was a col-collegiate basketball referee before I was a psychiatrist, and so I do have a very direct communication style, and I really like high-intensity environments that require de-escalation.

And so it would be difficult for me, I think, maybe it'll change as I get older, but I think it would be difficult for me to do a typical outpatient psychiatry clinic. And to your other point, I was advising a student yesterday who's torn between pediatrics. He really likes well-child visits, and he loved that, like, in pediatrics, you could really solve a problem, and the parents would look at you and be like, "You have really solved this.

Like, thank you, doctor." And then he's sort of considering child and adolescent psychiatry, and the meeting was about, like, which one? And it took everything in me not to be like, "Don't do it." Like, there's not a lot of gratification in this. A lot of the time, you know, you do the best you can. And obviously, there are exceptions, ADHD being a major one But you really have to be [00:46:00] okay just doing your best and understanding that you didn't create the system and you may not be able to solve everything in one visit in psychiatry.

So I totally appreciate that. 

Dr. Meghan Schott: And your student needs, probably needs to do triple board so they can decide more time to decide what they wanna do. Do they wanna go into pediatrics or they wanna go into psych- child psychiatry? 

Mark Mullen: Do you mean that? Should I tell them that? 

Dr. Meghan Schott: Yeah, I do mean that. Yeah. Like if that's what they're debating between, 'cause when you do the triple board, most of them end up going into psychiatry.

But I actually know some pediatricians that did triple board and they, that are mainly pediatricians first and they just ha- like the psych stuff that they can actually incorporate more into their practice because I think this year they finally said, "Okay, you have to have a certain number of months of formalized didactic training for, in pediatric world psychiatry.

And so they're getting more than they ever used to, but before they would get almost nothing. 

Mark Mullen: Well, thank you for that, and I will let them know. Dr. Shaw, thank you for coming on Psychiatry Boot Camp. It's been a pleasure to have you.

Thank you so much for listening to this episode of Psychiatry Boot Camp. If you're enjoying the show, we'd love to know what you think. We extra, [00:47:00] appreciate reviews on Apple Podcasts or ratings on Spotify. That's the best way to help the show grow. You can connect with us on Instagram or TikTok @psychbootcamp, and you can chat with the rest of the fun Human Content Podcast family on Instagram or TikTok @humancontentpods.

You can also contact me directly at psychiatrybootcamp.com. Full video episodes are now available on YouTube each week at Psychiatry Boot Camp. And thanks again, I'm your host, Mark Mullin. Our executive producers are Aron Korney, Rob Goldman, Shahnti Brooke, and me. Seasoned producers are Matthew Brodk and Amina Janjua.

Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. To learn about our program disclaimer and ethics policy, our submission verification and licensing terms, and our HIPAA release terms, go to psychiatrybootcamp.com or reach out to us directly with any questions or concerns. Psychiatry Boot Camp is a Human Content production.[00:48:00] 

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