A woman recently requested a medication evaluation at the suggestion of her psychotherapist. The caller told me her diagnosis was borderline personality disorder. She hoped medication might ease her anxiety. She also admitted that two other psychiatrists refused to see her because she was too “high risk.” I asked if she was suicidal. Yes, thoughts crossed her mind. However, she never acted on them, and was not suicidal currently. I was curious whether my colleagues recoiled at the caller’s diagnosis, her suicide risk, her wish for anxiety-relieving medication, or something else.
By definition, “high risk” medical and surgical patients face an increased chance of poor outcome. According to a British study, high-risk surgical patients are a 12 percent minority who suffer 80 percent of all perioperative deaths. High-risk pregnancies threaten the health or life of the mother or fetus; they constitute six to eight percent of all pregnancies. Various charts and algorithms identify the high-risk cardiac patient.
Historically, physicians and surgeons accepted high-risk cases. As one would expect, these patients had poorer outcomes and higher mortality. Doctors did the best they could, humbled by their limitations and occasional failures, spurred to treat the next such patient more successfully. However, recent social changes conspire to blunt this acceptance. Fear of lawsuits, stemming both from an active medical malpractice bar and patients’ high expectations, means that doctors, too, are at high risk. Increased reliance on outcome data and online reviews by patients may likewise lead some clinicians to cherry-pick cases that won’t mar their results. Patients at high medical or surgical risk now have a harder time finding a doctor who will see them.
No single hazard defines the high-risk psychiatric patient. There is a robust literature on young people at high (and “ultra-high“) risk for developing psychosis. There are well established risk factors for addiction. Patients have also been deemed at high risk psychiatrically when they leave institutional care without permission; when they are young unemployed women following discharge from medical ICUs; and when they are youths with “serious emotional disturbance” who receive public services. Having a psychiatric problem at all may be one factor among many that signals high risk in non-psychiatric medical settings.
However, “high risk” in psychiatry most often refers to suicide risk. A large literature relates suicide to demographics, physical health, psychiatric diagnosis, behaviors such as substance use, and so on. Unfortunately, a diagnosis of borderline personality disorder is associated with an 8 to 10 percent lifetime suicide rate. This is significantly higher than the general population, and on par with schizophrenia and major mood disorders. Did two psychiatrists refuse to see my caller due to her suicide risk? If so, do they also refuse those with schizophrenia, bipolar disorder, and major depression?
To the best of my knowledge, psychiatrists do not shun high-risk cases in order to avoid lawsuits or to improve their outcome statistics or online ratings. Psychiatrists are rarely sued, and few of us even have such statistics or ratings.
However, a 1986 study found (unsurprisingly) that patients’ suicidal threats were stressful for their psychotherapists. Perhaps the real question is: What kinds of stress should be expected in routine psychiatric practice, and what kinds are legitimately avoided?
We must acknowledge that every decision about joining insurance panels, setting fees, or limiting one’s practice in any way is a form of cherry-picking, broadly construed. The stresses of running a business and providing for one’s family are not unique to psychiatry. Everyone wrestles with balancing self-interest and other-interest. Yet these trade-offs are particularly glaring in heath care, including mental health care.
The law allows doctors to refuse service to anyone, as long as that refusal isn’t based on membership in a legally protected class, e.g., race or religion. This doesn’t resolve questions of ethics and professionalism though. I often turn down medication-only cases (although not the above caller) owing to my interest in psychotherapy. I’ve also written about avoiding private insurance contracts, and my mixed feelings about accepting Medicare. Of course, patient misbehavior may also lead a psychiatrist to turn down or refer out a case: inability to keep or pay for appointments, calling incessantly, making too many demands, etc.
I think avoiding suicidal patients is different. To me, a psychiatrist who avoids suicidal patients is like a surgeon who can’t stand the sight of blood, or an obstetrician who doesn’t like to think about where babies come from. Suicidal feelings are exactly why some patients seek our help. Yes, they are at high risk for a bad outcome. And I can vouch for the stress: in addition to being the target of numerous suicide threats and gestures, I have had one confirmed suicide in my practice, another that was equivocal (it may have been an accident), and likely others I don’t know about. It’s no fun. But in the end, the “high risk” belongs to the patient, not me. I do the best I can.
Come to think of it, a closer analogy is my declining to conduct ADHD evaluations in order to avoid being a gatekeeper for stimulant-seekers. I suppose here too the risk is theirs, despite my discomfort with gatekeeping and lie detection. This confusion — whose risk is it? — is tricky. Death, disability, hospitalization, and addiction are risks to the patient. Lawsuits, adverse outcome data, regret at taking the case, and the stress of uncertainty and self-criticism are risks to us. Some of the latter risks have always been par for the course, some are newer. Some are self-imposed. When we speak of the high-risk patient, let’s be honest about whose risk it is.
Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.
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