Deal with it

 Uncertainty is a regular part of life, not just medicine. I'm finding it particularly hard pill to swallow this week. 

We're taught throughout medical school to not let a suicidal patient past us. That we must ensure safety of our patient from diseases, from our neglect, and from themselves. It was never said, but the general message I felt in med school was 'if a patient dies by suicide and you didn't stop them - you've failed'. Certainly I don't want a single patient to ever die prematurely, least of all if I have a chance to prevent it. 

Yet in residency, we once sat down to a teaching session with a well respected and beloved psychiatrist who told us for some people, suicide is the only end of their illness. That after all the counselling, hospitalization, medications, some patients will inevitably die. 

I recognize this in many other diseases: I can only throw so many diuretics and blood pressure medications before a congested heart eventually fails. No amount of insulin is going to save some patients from the ultimate MI caused by diabetes. I cannot stop a burr of growth from taking over healthy tissues and prevent the cancer from spreading like wildfire in the end. Why, then, when it comes to chronic mental health issues, is the idea that I cannot treat with intent to cure everyone that much harder to swallow? 

But I digress. I had a young patient whom I was meeting for the first time in a busy, fee for service clinic. By which to mean I expected to spend 15mins and move on to the next patient if I can. For anyone who is not familiar with the workings of many family medicine clinics - take note. This is one of the many reasons we're probably 30-60mins late when you're in a rush for your appointment. I run over for these patients, as I hope you know that if you ever need me like this, I will run over time for you, too. 

This young person presented with an innocuous complaint, calling in to say they need a "refill". That's almost anything from "I've been stable on this statin/cholesterol pill for 10 years" to "lorazepam for my wildly uncontrolled anxiety". During the encounter they revealed various stressors to me. Work stressors of losing their previous job due to the pandemic and being unable to find a job where they live now. Why don't they move? They can't afford the rentals here in the city and their family member requires on-site care and can't do without. They didn't qualify for social supports and services based on various statuses. They don't see a way out. They've been using alcohol to cope with the stresses and pain. They know they're drinking enough to risk serious morbidity and mortality. They have, several times, combined other sedating medications and drugs in dangerous ways. They won't call the mental health crisis line because the crisis workers can't help find a job or solve their debts. They're not actively suicidal this very second. 

That is one of the distinguishing features on a safety assessment. If someone states that they are actively suicidal (and of course various other questions/assessments I review), I must "form" them. I put them under a psychiatric hold for their own safety. Shockingly/un-shockingly, the system for mental health has quick service for the acutely suicidal, but service access is much more difficult when you're "just" very depressed. The entire discussion of how healthcare systems have gotten to be like this and are buckling under the added pressure of the pandemic is a different discussion. For now it suffices to say that we don't have enough resources, period. 

But this young person isn't actively suicidal. They're very likely to die by substance use, whether intentional or not. I can't form them. I offered to call the acute mental health response team but the patient declined, and they are not in a spot where I can sign a form to force them to have a psychiatric assessment. They are "just" in a spot that so many others are. Trapped by the economic factors of lack of job prospects, lack of social and community level support programs, and social factors of family circumstances and coping mechanisms. 

Do I give them medications that they might overdose on? Do I not give medications for their crippling panic attacks that they have and will continue to buy off the streets from a possibly dangerous source? What happens if they go home tonight and drink their usual amount of alcohol, take the benzos that they're requesting/have bought off the street already, and overdose? How do I live with that? How do I prevent that? 

I'm fortunate enough to still be a resident and turned to my more experienced staff for help. Part of their answer is a hard pill that I have to swallow. Sometimes we just have to deal with that uncertainty. Sometimes in the brief time allotted in a family clinic encounter (we were now 90 minutes over time), we live with even more uncertainty. We've been told, time and again throughout training, you can't save everyone. I remember it as the mantra in medical school but didn't apply it to the mental health encounters. Sure, I can't save someone rolling through the ER with an aortic dissection (4/4 aortic dissection cases I've seen were fatal). But this person is alive, in front of me, and it feels like if I can't find the solution for them, they won't be alive for a next time. 

And I guess sometimes that's something we have to live with. A staff shared with me about a patient, ill with mental health issues, who did complete suicide under the staff's practice. But we really can't save everyone, we can only do our best by them. Underlying this is we still have other patients requiring our care in the rest of the clinic schedule, and we need to do our best by them, too. 

So I guess we just deal with the sometimes nightmare-inducing unknown and uncertainty. 

FYI this particular patient did seek and get help. They're doing all right, now.