Psychiatrist Maria wonders if hospitalizing patients at low clinical suspicion for suicide is a form of defensive medicine:
Some psychiatrists routinely hospitalize patients (through coercion, either with or without the “help” of friends, family, et al.) who endorse suicidality when “clinical suspicion is low” that the individual will actually commit the act. The belief is that if someone is in the hospital, the risk of suicide drops significantly””after all, the ward is locked, there is less access to means of killing oneself, and there are people (nursing staff) presumably monitoring the situation. There is also the sense that the psychiatrist, by admitting this person, is “doing something”, versus asking the patient to return for an outpatient follow-up appointment the next day, which seems more like “not doing much”.
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{ 6 comments }
Big, big, big and very expensive problem.
Suicide is like chest pain, in terms of mandatory admission. If someone tells you they are currently thinking about killing themselves, you have to admit them.
A common question is where do you admit a person that says they are thinking about killing themselves AND they have chest pain.
Rack:
Baloney. Admission is a medical procedure that has risks as well as benefits. Patients should be assessed before any procedure to determine if the risks exceed the benefits. If they don’t, then you don’t do the procedure. The risks if psychiatric hospitalization in a patient who is factitious are numerous including positive reinforcement of dyfunctional behavior, injury of or by other patients. opportunity for further manipulation for drugs of abuse, reinforcement and reward of avoidance of responsibility. In short, when it isn’t needed, it may well make the patient worse. The problem is that most admissions in my community don’t include a qualified assessment. The ER docs (understandably) just write “SI” and the psychiatrists often don’t see the patient until three days after admission.
I treat patients in my office with “SI” every day of their lives, without admitting them to the hospital. I have sent hundreds of patients home from ER’s following wrist slashings, overdoses, and threats of the same without losing one. Even if I did lose one, it doesn’t mean that the risk wasn’t worth it for avoiding the deleterius consequences of inpatient treatment.
Doctors are paid to think and exercise judgements, not engage in kneejerk protocol application.
Anonymous 10:08:
I was exagerating a little in my comments above, and they apply to mainly to seeing unfamiliar patients in the ER. When I was actively practicing primary care/outpatient psychiatry I sent patients home from the clinic with chest pain and with suicidal ideation (usually not both at the same time). Homocidal ideation, however, I didn’t compromise on. Homocidal ideation, in any setting, usually gets you admitted.
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“Doctors are paid to think and exercise judgements, not engage in kneejerk protocol application.”
A lot of doctors aren’t paid for their ER work, which is why I don’t do it anymore
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