Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”
Dr. Otto Kausch
Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.
Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.
Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.
A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”
The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.
Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.
After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”
However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”
And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”
In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.
I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.
An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.
An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”
Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”
Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.
So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?