Last week, a few days after I testified to the Washington state House of Representatives Committee on Health and Wellness that doctors and nurses ought to face required suicide-prevention training, I received a call from a newspaper reporter. He wanted to know why I was so adamant.
I told him what I tell the professionals I train: “You can’t make a diagnosis you don’t know, and you can’t treat a problem you can’t diagnose.”
Or, as I sometimes put it, “If you don’t want to know if your patient has a temperature, then don’t take his temperature.”
As regards suicide, if you don’t want to know if your patient is suicidal, then for Pete’s sake don’t ask! Because if you ask and the patient is suicidal, you’ve just created a big problem for yourself. And it is usually a good idea to have a solution to a problem you just asked for.
Most doctors don’t. Including my own. With exceptions, routine avoidance of this diagnostic probe is the rule. The danger is this: Risk you don’t know about cannot be managed, mitigated, or controlled. When the Buddha said, “Recognize all danger and avoid it” apparently there were no doctors in the audience.
Each of us recognizes danger and tries to avoid it every day. We don’t drive unbuckled through freeway traffic. We don’t drink and drive. We walk carefully on ice and make sure our children brush their teeth.
Ask yourself, “Would I fly on a plane whose pilot had very little training and doesn’t know what a pre-flight checklist is?”
Ask yourself, “Would I send my suicidal brother to a doctor who has very little training in suicide prevention and doesn’t know what a suicide checklist is?”
The problem with the S Question is that if the patient is positive for suicidal ideation, a past suicide attempt, or a current plan, now you have to do something. And that something matters.
I explained to the reporter that in the absence of specific training on how to detect and diagnose suicidal behavior it is essential that clinicians be able to A) ask the suicide question in a way that the patient is not encouraged to say no, and B) conduct a structured interview to learn if the patient desires death, is planning to die, and how, where, when, and why.
If you don’t want to know all this, here’s how to get patients to lie to you: “Given all you’ve told me, you’re not suicidal are you?”
Patients are polite; they would rather lie to you than upset you.
The majority of mental health care is provided by non-psychiatric physicians. Since the majority of people who end their own lives suffer from an untreated or undertreated mental illness, and given that they are cared for by these same professionals, it only makes sense that improving their ability to diagnose would improve their ability to treat.
But rather than lecture to you about all of this, how about I tell a personal story about my own doctor.
Now retired, Dr. Fred Viren is an internal medicine physician still conducting research and training in his subspecialty.
As my personal physician he has followed my suicide prevention work for better than 30 years. When he retired, we moved from a professional relationship a more personal one. He’s an avid fly fisherman and we see each other on the stream from time to time, where it is much easier to talk about fly selection than blood pressure and my eating habits.
During my doctor visits I taught Fred how he could routinely ask his patients about suicide. He then instituted the practice, not with everyone, but with people that worried him or about who he felt some concern.
Some weeks later I got a call at my office:
“Paul, I just asked one of my older depressed patients whose wife died last year and who has a low-grade prostate cancer, if he was having thoughts of suicide. He is! Now what do I do!?”
Fortunately at the time I was, among other jobs, the Director of Elder Services at Spokane Mental Health.
I asked, “Can you keep the patient there for a little while?”
He said, “Sure I know the patient well.”
I was then able to send a psychiatric nurse and social worker to his office to see and assess the patient, and to coordinate a treatment plan. Turns out this older gentleman – I’ll call him George – had also lost a brother to illness within a year, and was terribly isolated. George was seriously depressed and required a brief hospitalization at our local inpatient psychiatry unit. After a week of getting his sleep reordered and his brain functioning close to normal limits, he made a wonderful recovery, got back on his feet, and eventually became a volunteer driver for our Care Cars program at Elder Services program in Spokane County, a division of Frontier Behavioral Health. George died a few years later of natural causes, but his remaining time on the planet was spent with purpose, meaning, and in the service of others.
Let me end this post with a couple of observations and links.
There are at least 10 reasons why doctors and nurses don’t want to be required to complete some kind of suicide prevention education or training. A colleague and I published an academic paper on this question in the Journal Suicide and Life-Threatening Behavior, wherein we attempted to counter these arguments with ones of our own.
Academic publications are just like blog posts, but with the nerve extracted. You can find the copyrighted article at: http://onlinelibrary.wiley.com/doi/10.1111/sltb.12010/abstract, and you may have to pay to read it. Or, you can find the pre-publication version (which does not violate copyright law) at: http://www.qprinstitute.com/pdfs/PCP%20SLTB%20Word%20F_SLTB9_24.pdf
It is not that doctors and nurses don’t know there’s a problem. They do. And they care. It’s just that they don’t have enough time or help available from mental health professionals to whom they could refer the suicidal patients they find. Given the pay and hours and cost of training, there will never be enough mental health professionals to take on this job. So in my view doctors and nurses need to step up and learn how to help these patients themselves.
Personally, I’ve been working with schools of nursing education to see if nurses could not take on the role of suicide care in the front lines of medicine. We are testing embedded training in one college nursing course now and some nurse educator leadership believes nurses could do this job as well as anyone. Nurses are already in place and are expected to deliver most of the medicine this country needs in the years to come. As a profession they already enjoy great respect from the public. Who doesn’t love a nurse?
Here’s a link to one informative article on the detection of suicide risk in primary care, “Let’s Just Not Talk About It: Suicide Inquiry in Primary Care” published by Dr. Feldman and his colleagues in the Annals of Family Medicine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/. It a good study and a good read.
Finally, my friend and colleague Jenn Stuber published this op-ed in the Seattle Times just a few days ago: http://seattletimes.com/html/opinion/2022749817_jenniferstuberopedsuicideprevention27xml.html.
Oh, and that reporter who interviewed me and provided the lead to this blog post just published his story on what’s happening in Washington state. It’s an excellent summary at: http://www.auburn-reporter.com/news/242804151.html
Thanks for your time.
Suicide is not so much a tragedy of what was, but what might have been.