Tuesday, March 03, 2009

You Didn't Even Ask?

Okay, I'm going to ramble (I know it, even before I've started) and I don't quite know where I'm going with this. Please notify me if I get there.

There's an assumption in medicine that the responsibility for pulling out the truth rests with the doctor. Really? I don't know, and I've never seen it stated as such. It feels like it's there, though, in insidious ways that leave us with the sense that if we don't ask the right questions, don't elicit the right information, that the fault (and, yes, I think I mean fault), and the liability, is with the physician.

Let me explain a little better: a patient commits/attempts suicide...people (which people? I don't know: People! Perhaps everyone. Lawyers, supervisors, family members, other physicians) will ask: Did the psychiatrist ask if he was having suicidal thoughts? A plan or intent? In the two clinics where I work, there is a check-off box on the doctor's progress notes regarding Suicidal Ideation. It's a good jog to the memory to remind us always to ask, but it's also intrusive. It must be checked off and the doctor doesn't have the space to decide it's inappropriate to ask that particular question on that particular day. Some might say it's always appropriate to ask about suicidal ideation, but when I'm seeing a patient whom I've known for years, who has never been suicidal, who tells me they are doing well, feeling fine, well, it sometimes feels a little weird for me to ask, "Are you having any thoughts about hurting yourself?" Them's the regs.

But it's not just suicide, or homicide, or any form of violence. It's other things as well. Roy mentions in his Xanax post that the doctor needs to ASK the patient about a history of substance abuse to find out. Oh, but patients can lie, or forget, and doesn't everyone know Xanax is addictive? Shouldn't a patient with a history of addiction volunteer this information to any doctor who may prescribe an addictive drug that will re-activate a past problem?

It's not mental health issues, it's all of medicine, though certainly, each specialist feels an obligation to attend to his organ system. Do internists second-guess themselves if someone walks out and has a heart attack: "Oops, I forgot to ask if he was having chest pain." Do they check their notes and hope they've documented an appropriate assessment for cardiovascular disease?

So what's my point? It's certainly not that we shouldn't ask questions. We should. And there are issues that might not be obvious to the patient, things they might have forgotten or may not know are relevant-- like asking about a past history of mania/hypomania before prescribing an anti-depressant. But, I think, at some level, we've taken on the burden of blaming ourselves (or our colleagues) if something goes wrong and the doc didn't ask. Maybe it's a fallout from the malpractice era: in terms of a lawsuit, it's probably not good form to have a bad outcome about something one didn't ask about. There is also that sense that if you asked, and the patient said No, then how could we know otherwise? It's not that we don't feel sad about a bad outcome, but if there's the sense that all that could have been done was done, at least there's not that feeling of responsibility.

Sometimes, though, it doesn't just feel like a moment of omission, it feels (to me, at least) as though we blame ourselves and each other for a bad outcome if we didn't ask the right question, as though it's our fault, like we've caused something bad to happen, or at the very least, failed to prevent it. We blame ourselves, we finger-point at our colleagues.

I told you I was going to ramble. Well, what do you think?


shrink on the couch said...

I think we in the mental health and medical professions generally understand exactly your point. And sympathize. Asking about suicidal ideation every single visit? Does that mean we also ask about homicidal, hallucinations, everything under the sun, etc. every visit? We'd never get to the real work of therapy if that's the case. This is an example of the fallout from a litigious society. It's frustrating and adds a very stressful aspect to the freedom of the work we do.

I wish there was a legal precedence established (is there? is there not? I don't know) that the larger burden should fall on the patient to inform the doc --after the initial exam. Asking in the right context is good practice but should be viewed as an additional precaution rather than standard practice.

Anonymous said...

I am really glad my psychiatrist does not work at your 2 clinics. He has NEVER asked me if I have suicidal intent, even when I have been verging in that direction. Instead he approaches the topic in a variety of artful ways. Recently when I was really down he said something like "So is this something you might be able to work through one step at a time or do think it's time to just give up?" His wording was better...AND he ended with a twinkle in his eye with the implication being that suicide would be the wrong choice. I was leaning more towards just giving up, but he presented the possibility of working through it and even in a depressed state I could see the logic of that. So we went forward with a discussion of how to change the situation. Sometimes if I am really down he changes the topic to something I am interested in and sees if he can engage me in an interest. He probes about whether I have been taking time to pursue leisure activities he knows will give me pleasure like listening to music, reading a book, taking a hike. It can be MORE productive to lead a client down the path of "this is a way out of how you are feeling" than to explore suicide in depth. To follow the suicidal thoughts at a session reinforces them, don't you think?

What about giving your clients a small form to complete in the waiting room with boxes to check like "I feel suicidal", "I have planned the suicide" etc. You'd know at a glance if you need to go down that road, you would have a written record, and you would not have to go down that road in every session.

Anonymous said...

What about giving your clients a small form to complete in the waiting room with boxes to check like "I feel suicidal"
There are screening tools that do ask those questions. eg Goldberg/Becks
Sometimes it seems a little impersonal tho to just give a checklist.

Timing of the post couldn't be better... I've just had a sentinel event. My first.
Might be MH related - might be medical. Literally - today; so no idea as yet.
My checklists have the same questions - and in the absence of completing one (hadn't got that far - he was new on the books; lame excuse?) - I am now in a position where I will be called on it and asked for state of mind evidence.
There weren't enough indicators for me to be actively concerned - and there were protective factors anyhow.
But I'm going to get called on it - regardless of causation - by the coroner. Simply because it was one of the questions to ask....

I agree - if the questions are pointed/directed - why be trained in the job?

Midwife with a Knife said...

Hm... you know, in any patients who state that they have a history of depression (or any other psychiatric disorder) my residents have been asking EVERYBODY about suicidal or homicidal ideation (and ordering inpatient psychiatric consults on everybody who even admits to a history of depression, whether or not they have a history of symptoms). I try to correct it case by case, but the residents outnumber me, and all I can come up with is that someone is telling them that this is necessary (although I can't figure out who).

I also have to say that as a doctor, although checking in with someone with a history of depression about it during the pregnancy and especially postpartum is important (something like, "How's your mood?"), it seems intrusive to ask about suicidality at every single prenatal visit. Also, the residents send anybody who answers yes about suicidal ideation to the psych ED, which, to me, implies that they really don't know how to assess suicidality.

As a patient (with a psychiatric history that is, admittedly, pretty bland compared to many), if I'm at my gastroenterologists to talk about my UC, it's fine if he asks about my mood, but it would seem weird and intrusive to me if he asked me about suicidality out of the blue.

Also, were I admitted for a medical condition, unless I was actually depressed or something, I really don't want a psychiatric consult from the inpatient team. I mean, I'm sure they're nice, but I have my own doctor.

My psychiatrist's office has one of those little check-box forms, and I have to say that I'm not sure I would check it even if I were having suicidal ideation (which I'm not). Somehow it seems like it might be one of those things that's easier to talk about if someone actually asks you about it, you know? However, if someone's stable or doing well, there may be no real reason to talk about it.....

Anonymous said...

I am a mental health professional and also see a psychiatrist. I have never been suicidal and if my doctor asked me that at every visit, I would find a new doctor. I would feel like the doctor did not know me at all.

Anonymous said...

Dinah, in the interest of not neglecting a suspicion based on the last post or two...

Got guilt?

Dinah said...

MWAK: A psych consult for every patient with a history of depression? I can't quite imagine.

Gentle reader: Something strikes a cord and inspires me to write. Not guilt, this was inspired by a conversation with a friend who made a comment about a psychoanalyst who never asked about suicidal ideation and got me thinking about why it is that we now feel it's our responsibility to actively ask, while in traditional psychoanalysis such questions aren't act and the changing standards in psychiatry.
Last post was inspired when something bad happened to a supervisee's patient while he was away. I generally disguise the scenarios a little, while leaving the issues they bring up for me, not so much because I'm feeling guilty, or looking for answers, but more because they got me thinking, and I like hearing how others feel.
I'm not sure what a checklist would do--- I see plenty of people who are chronically suicidal, and I've seen people who say they aren't thinking about violence who leave and do something unthinkable within hours....we're not very good at predicting the future...

Oh, I may make this into it's own post, but for now my co-bloggers are on a role.

a psychiatrist who learned from veterans said...

I completely agree. However the jury is out if empathy is more important than robotic questions.

Anonymous said...

Sorry, did not mean to pry (though I know you aren't implying I was). I tend to throw manners to the wind and indulge my loose tongue on the internets. I must've realized it on some level at the time given my chosen alias.