Oh Doctor, Where art Thou?

Thank you for returning to this blog. And if this is your first visit, welcome.

While this is not a news blog per se, big fish are being fried.

Last Wednesday in Olympia, Wash., several of us testified before the Health Care and Wellness Committee of the House of Representatives in support of House Bill 2315. If passed, the bill would require a minimum of six hours of training in suicide risk assessment, treatment, and management for all primary care providers.

Here’s the target list: chiropractors, naturopaths, all nurses, osteopathic physicians and surgeons, osteopathic physician assistants, physical therapists and assistants, physicians assistants, and physicians. Six hours, over six years. Either get trained or lose your license to practice.

Why a requirement? Don’t they know this stuff already?

No, they don’t. Persistent, willful professional ignorance has never solved a serious public health problem. Look no further than the resistance to HIV-AIDS education in the early days of the epidemic.

Louis Pasteur had problems convincing doctors that something called “bacteria” were killing their patients. Untold thousands of people died from preventable infections before physicians were convinced that washing their hands between surgeries or delivering babies was a good idea.

When I was a boy, TV doctors sold cigarettes.

Global research has repeatedly shown that primary care providers have the most frequent “last contact” with those who die by suicide. These last contacts amount to missed opportunities to observe, recognize, detect, routinely screen, assess, and respond to suicidal people who may have started on that terrible, lonely journey to self-destruction.

Denial is not a river in Egypt but rather a professional belief system that says, “I don’t like to talk about suicide with my patients because I am not comfortable with the subject, and I might actually cause them to kill themselves if I do.”

Times change, research informs, and avoidance of the uncomfortable costs lives.  When I train physicians in how to screen for suicide risk, I often ask them, “Which is more difficult, conducting your first DRE (digital rectal exam) or asking if a patient is considering suicide?”  Finding: DRE probes are easy, suicide probes are hard.

Too many professionals in primary care fail to understand that if they do not have “the conversation” with their suicidal patient, the suicidal mind may perceive this indifference as permission to proceed — thus does inaction inflame the infection of hopelessness. 

If HB 2315 were to pass, and with medicine in the game and taking the point (I am certain once they see the direction the parade is headed they will rush around to get into the lead), the suicide prevention movement would soar. With Washington state leading the way, others would follow. Research funding would jump. Obama’s Decade of the Brain would suddenly find new and urgent exploratory directions. Medical and nursing school curricula would change, practice standards would rise, and suicide rates would drop. As a country we could take pride in knocking down the last vestiges of medieval ignorance, fear, and stigma about suicide.

The practice of medicine is old, suicide prevention is new, and we need their help at the helm. Resistance to change is greatest among our oldest institutions; universities, medicine, and the Roman Catholic Church. But the suicide prevention movement is swirling all around medicine; and as I like to remind people, just because you close your eyes doesn’t mean they can’t see you.

While professionals testified for and against 2315, and suicide survivors captivated the committee, I was most proud of two young suicide–attempt survivors who told their personal stories. Each had encountered primary care professionals on their journey toward a violent death. In both cases their primary care providers failed to recognize, screen for, ask about, or otherwise attempt to intervene in their desperate journey to a suicide attempt. In the young man’s case, and on his last visit, he was given sufficient medication to complete a lethal overdose.  Except for the heroic efforts of others after his OD, he would have died.

Public health research has shown that data do not change hearts and minds, stories do.  And these stories were spellbinding.

Each speaker was given 2 minutes. Here’s my testimony:

Madam Chair, and members of the committee, my name is Paul Quinnett.  I live in Cheney. I am a clinical psychologist and suicidologist.

In addition to being a clinical assistant professor at the University of Washington School of Medicine, Department of Psychiatry and Behavioral Science, I am the CEO of the QPR Institute, an educational organization dedicated to preventing suicide. More than 7,000 certified QPR instructors have trained more than 1.5 million people in 18 countries in how to prevent suicide. In full disclosure, suicide prevention education training is our only mission and training fees sustain our small, veteran-owned business.

I’m not here to tell you what you already know. I am here to create a sense of urgency.

This past spring I attended a meeting of national leaders to address the 28% rise in suicide rates among our work force, and the expected rise in veteran and older American suicide rates in the coming years. All agreed: We must institute actionable research and available best practices now.

Not later. Now!

In training, we have two choices: voluntary or mandatory.

In my experience, voluntary training is desirable, but insufficient.  Given the choice and the evidence, most professionals avoid the subject of suicide.  Voluntary training has been recommended for decades, and nothing much has happened, or we wouldn’t be sitting here today.  Voluntary training is a failed strategy. Further debate or delay will only perpetuate the status quo, which now amounts to “willful ignorance.”

As a psychologist, I don’t want legislators telling me how to practice my profession. On the other hand, my ethical obligations require me to not practice out of my area of competence. Thus, if I am seeing suicidal patients, I should either a) screen and refer them to another qualified practitioner, or b) complete recommended best practice training. To do otherwise is to place my patients at unnecessary risk.

You will hear arguments that if this training is mandated, all kinds of other training mandates will follow. Maybe, but I don’t think so.

From a public health perspective, no topic is more urgent than to address what it is people are dying from. Therefore, the litmus test should be: if mandated, will this training save lives? You have your own DOH (Department of Health) report to answer that question.

As the past chair of the Washington State Examining Board in Psychology, my mission, and the board’s, was to protect the public, not the profession. It still is.

Given recent advances in suicide prevention knowledge and suicide care – and given the resistance to voluntary training thus far – I wonder how long licensing boards can continue to assure the public that those they license are adequately trained prevent suicide deaths among their customers. Given that an estimated 32% of American suicide victims die while in the active care of a  healthcare professional, I submit they cannot. And if they cannot, how is the public to be informed and protected?

I do know this: Continued professional risk blindness about the needs of suicidal patients currently in our care is not acceptable.  

Finally, recent publications by successful healthcare organizations aiming to achieve “zero suicides” among their patients all require mandatory employee training, and even competency testing. Not voluntary, not elective, but mandatory training.

If Washington is to lead the way to “zero suicide” in healthcare settings, passing 2315 is a major step forward. Thank you.

That was my testimony. Two minutes was not enough. I was talking when the yellow light came on. I was talking when the red light came on. I was talking when the committee chair told me to shut up.

If I’d had another minute I could have explained that psychologists like me belong to a special self-help group; it’s called On and On and On and On….

Pushback testimony was clear: We don’t want to be told what training we need. One committee member asked one professional group, “What percentage of your membership have had suicide prevention training?” The flummoxed leader had no answer.

Changing the status quo requires us to blow a few people up in their suits, or at least cause their food to go down in lumps. I think it was a good day for our side. But of course as a chronic optimist I live on soap bubbles.

One supportive email: “I’m so proud of the testimony this morning – the gravity in testimony had me in tears . . .  I believe the message was well received and I could not agree more at the embarrassment of the testimony of those opposed to mandatory education – they obviously don’t get it.” 

This was from a professional family who had recently lost their gifted son to suicide while in the care of health professionals.

To see what happens next, watch this space.

Key links:

Pat our leader on the back: Tina Orwall (D-33rd) @ http://www.leg.wa.gov/house/representatives/Pages/orwall.aspx

Read 2315: http://apps.leg.wa.gov/documents/billdocs/2013-14/Pdf/Bills/House%20Bills/2315.pdf

Analysis of HB 2315: http://apps.leg.wa.gov/documents/billdocs/2013-14/Pdf/Bill%20Reports/House/2315%20HBA%20HCW%2014.pdf

Related op-ed: http://www.spokesman.com/stories/2013/dec/29/guest-opinion-suicide-bills-are-a-game-changer/

I submit to you nothing is intractable. If your goal is deemed unreachable and impractical by others, you are on the right track to make a difference in this world; when they think you are utterly unreasonable you have all the confirmation you need to begin.

Dr. Paul


7 thoughts on “Oh Doctor, Where art Thou?”

  1. Excellent, Paul. I will encouraging others to read this as we try to get mandatory training for mental health and substance abuse professionals here in Tennessee. Same pushback. Same dated arguments against training. Thanks.

  2. I always ask, how many lives would you have to save for this to be worth twenty hours of training? How many hours would you want someone else to have if your best friend were in crisis and you had not bothered to learn how to help them?

  3. “We can give you a half hour…” I have spent hours planning and thinking of how to get buy-in during that half hour. Stories from their own world were the best–stories of how the system worked and tragically failed. Home-made pie, good tea, water and coffee, a business card, along with an offer for follow-up training and 24/7 support for screening engendered off the record “help me” phone calls and requests from staff for follow-up training. Systems (medical, educational, emergency response…etc.) are always fearful of lawsuits–mandatory training can assuage lawsuit fears and save lives. Paul–please keep living on those soap bubbles!

  4. Maybe part of the problem of resistance from our professionals lies in the difference between the “Original” and “Modern” Hippocratic Oaths;

    Interestingly, in the “Original Hippocratic Oath”, taken by doctors before being changed in 1964, states; “…I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone…I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion”’ (From Wikipedia, the free encyclopedia).”‘ Had the Supreme Court taken this into account some 56 million unborn children would not have had “harm” done to them.

    Unfortunately, the “Modern Hippocratic Oath” now states these alarming and conflicting statements; “…But it may also be within my power (the doctor’s) to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God…” (Louis Lasagna, 1964 Academic Dean of the School of Medicine, Tufts University).

    Seemingly we have gone from a culture of saving lives to a culture of “play(ing) at God”.

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