Dr. Brown's Psych Commute

About Dr. Brown's Psych Commute

Thoughts on psychiatry, medicine, neuroscience, artificial intelligence, problem-solving, and decision-making from a practicing physician, psychiatrist, and neuroscientist recorded during his commute from work. brandonbrownmd.substack.com (https://brandonbrownmd.substack.com?utm_medium=podcast)

Publisher

Brandon Lee Brown, MD

Category

health & fitness · science

Language

en

Explicit

No

First episode

14 Nov 2025

Latest episode

4 May 2026

Latest episodes

33 episodes in the feed.

1. 

   4 May 2026

   #31 - DEAPL for making clinical decisions

   In this episode of The Psych Commute, Dr. Brandon Brown introduces a practical clinical decision-making framework: DEAL and its more detailed version, DEAPL, designed for moments of uncertainty when time and information are limited. Using a tense inpatient case of a severely dysregulated patient with seizure-like activity in a resource-constrained psychiatric setting, he walks through how to systematically define the problem, enumerate options, assess whether you have enough information, predict possible outcomes, and ultimately choose the path that minimizes downside risk. The episode highlights how even in the absence of definitive diagnostics, structured thinking can guide safe, rational decisions and offers a mental model clinicians can carry into any challenging situation. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit brandonbrownmd.substack.com (https://brandonbrownmd.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

2. 

   18 Feb 2026

   #30 Why I write my notes backward

   I write my notes backward. Not in the traditional SOAP format (Subjective, Objective, Assessment, Plan), but essentially in reverse: Assessment & Plan → Data (Subjective + Objective) So instead of SOAP, it’s more like AP–SO. This format isn’t unheard of in medicine. It’s fairly common in internal medicine. But in psychiatry, it’s unusual enough that when colleagues cover for me, they sometimes copy my note forward and rearrange it back into standard SOAP. So clearly this is either misunderstood or mildly offensive to some people. Let me explain why I do it this way. At the very top of my note, I put a brief reason for admission: John Doe is a 56-year-old male with a history of schizophrenia and hypertension admitted for acute exacerbation of psychosis in the setting of medication non-adherence. 1. Running Hospital Course Next, I maintain a running hospital course, updated daily. I’ll structure it by hospital day: * Hospital Day 1: Admitted for psychosis. Started risperidone 1 mg BID and amlodipine 5 mg daily. * Hospital Day 2: Continued disorganization and auditory hallucinations. Increased risperidone to 1 mg AM / 2 mg PM. Just one or two sentences per day. Why? Because at discharge, I can copy this running course directly into the discharge summary. In Epic, there’s a built-in AI summarization tool that converts it into paragraph form. So I’m essentially writing my discharge summary in real time, a little bit each day. It saves me a ton of cognitive load at the end. Problem-Based Assessment and Plan After the hospital course, I move directly into a problem-based plan. Each problem gets its own header: # Auditory hallucinations / disorganized thought Under that: * Working diagnosis: Schizophrenia * If needed: Differential diagnosis * Workup (labs, studies) * Treatment plan If it’s straightforward, e.g. known schizophrenia with medication non-adherence, I keep it simple. If it’s undifferentiated, like: # Erratic behavior Then I’ll structure it more explicitly: * Working diagnosis: Psychosis unspecified * Differential: Substance-induced psychosis, schizophrenia, schizoaffective disorder, acute mania, encephalopathy * Workup: labs, UDS, imaging if indicated * Treatment plan If it’s complex, I’ll add some prose explaining my reasoning, for clarity and for liability purposes. But I generally don’t write long narrative assessment paragraphs the way many psychiatry notes do. The problem list always includes: * The primary psychiatric problem(s) * Medical comorbidities * Risk assessment and mitigation (suicide precautions, fall precautions, etc.) * Discharge planning And yes, I start thinking about discharge on day one. Are they going back to a shelter? A group home? Do we need a substance use referral? Guardianship? Long-acting injectable planning? That’s all part of the plan. Then Comes the Data Only after I’ve written the assessment and plan do I move to the data section. That includes: * Subjective * Objective * Labs * Vitals * Mental status exam * Physical exam To me, the subjective is just data. What the patient tells me is important, but it’s still data that feeds into the larger synthesis. I don’t start with a long narrative of what the patient said and then slowly build toward a conclusion. I already know what I’m treating and what decisions I’m making. The data supports that. Why This Works Better for Me 1. It Reflects How I Actually Think When I see a patient, I’m already forming an assessment and plan in real time. The note should reflect that. Starting with the plan forces clarity: * What are the actual problems? * What am I doing about them? * What’s the working diagnosis? * What needs workup? Once that’s clear, the subjective and objective sections become focused. I’m not transcribing everything the patient says. I’m documenting what’s relevant to the clinical questions I’m answering. It’s a filter. 2. It Improves Readability Let’s be honest: most people reading notes want to know the bottom line. If you’re covering me tomorrow, you don’t want to scroll through three paragraphs of subjective narrative to find the risperidone dose change. You want the assessment and plan. So I put it at the top. 3. It Keeps Me Focused When I’m writing multiple notes in a row, it gets tedious and I lose my attention especially when starting with the subjective. If I start with assessment and plan, I’m forced to: * Confirm diagnoses * Adjust meds * Update orders * Address risk issues * Think about discharge That’s the high-value work. Once that’s done, filling in the data is relatively mechanical. It also helps me avoid missing order changes. Writing the plan first sometimes reminds me of something I forgot to put in. A Simple Template Here’s a simplified version of what this looks like in practice. Reason for Admission 56-year-old male with schizophrenia and hypertension brought in by police for erratic behavior in public in the setting of medication non-adherence. Running Hospital Course * HD1: Admitted for erratic behavior, appears to be psychosis whether primary or secondary. Started risperidone 1 mg BID. Continued amlodipine 5 mg home med for HTN. * HD2: Persistent AH and disorganization. Increased risperidone to 1 mg AM / 2 mg PM. Assessment & Plan # Erratic behavior * Working diagnosis: Psychosis, unspecified * Differential: Substance-induced psychosis (UDS+ for cocaine), schizophrenia, schizoaffective disorder, mania, delirium, medical cause * Workup: CBC, CMP, TSH, UDS * Treatment: * Risperidone 1 mg AM / 2 mg PM * Monitor EPS, prolactin * Consider LAI prior to discharge # Hypertension * Continue amlodipine 5 mg daily # Risk Assessment / Mitigation * Suicide precautions: Q15 checks # Discharge Planning * Anticipated discharge to group home * Coordinate outpatient psychiatry follow-up * Evaluate for LAI prior to discharge Data (abbreviated) Subjective Patient reports ongoing voices commenting on behavior. Denies SI/HI. Reports poor sleep. Objective * Vitals stable * Labs pending * MSE: Disorganized thought process, AH present, insight limited * PE: No rigidity in UE This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit brandonbrownmd.substack.com (https://brandonbrownmd.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

3. 

   17 Feb 2026

   #29 Simulated Case: Altered Mental Status

   On this episode of The Psych Commute, we try something a quite different. Instead of discussing a random idea as I drive home as usual, we run a fully simulated inpatient consult using AI voice actors (but I wrote the script with no AI involvement). The patient: a 65-year-old nursing home resident with schizophrenia sent to the ED for “altered mental status.” The workup is normal. The ED thinks it’s psychiatric. From there, things start to get complicated. This episode focuses much less on interview technique and much more on clinical reasoning and management. I’m experimenting with this format, so I’d genuinely like to know if it’s useful, useless, or somewhere in between. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit brandonbrownmd.substack.com (https://brandonbrownmd.substack.com?utm_medium=podcast&utm_campaign=CTA_1)

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Guest appearances

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