This commentary is by Diane Roston, M.D., medical director of West Central Behavioral Health in Lebanon, New Hampshire.
A friend contacted me about her adult daughter who had lost her job, was drinking alcoholically and was considering suicide. I carefully considered the services my friend’s daughter should receive to help her recover.
As physicians, we are trained to serve those in need and, at the very least, to do no harm. My friend and her daughter had reached out to several private-practice psychiatrists, all of whom said they had no openings for a new patient.
In contrast, in community care, the expectation is to maintain an open door, to serve the general public, including the underserved who can’t find care elsewhere. In short, anyone in need.
The community mental health clinic, currently depleted of therapists, community support specialists, supported employment specialists, and most other staff, cannot provide care to all who need it.
Knowing this, I tell my friend, no. Right now the clinic doesn’t have the resources to serve your daughter. If she is in imminent danger, take her to the emergency room or call a crisis hotline. Don’t let her die.
Sadly, the life preserver of community care is itself in need of rescue.
Another: A 25-year-old man has been feeling depressed and hopeless, and has been missing work. When he is stressed, he cuts his arm to watch it bleed.
When he calls the clinic, the intake specialist evaluates his situation carefully. Can the clinic serve him? No. The clinic doesn’t have staff at this time to provide the care he needs. We offer alternatives. Please call your primary care doctor. Go to the emergency room, call the mobile crisis team or call a crisis hotline if needed. Just don’t give up.
“No” is a common response in medical care these days well beyond psychiatry. A college student is told that, due to new regulations, he can no longer get his tetrabenazine to treat muscle tics, even though it has been a lifesaving medicine for him — not in terms of quantity of life, but of quality. How would this patient’s life be altered if he had unpredictable, disfiguring facial twitches, maybe even random vocal explosions?
Another patient is told that cataract surgery cannot be scheduled for one year due to a shortage of ophthalmologists. Twelve months of blurry vision.
And try to find a primary care provider if you don’t have one. The answer is “no.” Wait. Wait longer. Hope you don’t need medical care.
These days, every medical provider I know is doing their best to stay afloat emotionally — with too few resources, too many patients, and more potential patients on the dock waiting to come on board. Too few doctors. Too few nurses. Too few therapists, phlebotomists, social workers, case managers, professionals in all health care fields.
Two state mental hospital units have had to close intermittently due to the nursing shortage. Many of the med/surg nurses in a local hospital are traveling nurses, without whom these units might also need to consider intermittent closing — an unacceptable option.
Fortunately, people in immediate need turn to mobile crisis teams, urgent care centers, emergency departments, who do their best to provide stabilization. Thank goodness for these services. In contrast, people needing ongoing care for chronic illness are struggling to find it. As often as not, when they seek care, the answer is “no.”
We know how this situation threatens the health of people needing care. But what about the impact on health care providers?
In a recent commentary, Christian Anthony Archer, M.D., describes the emotional burden of this situation on health care providers as “moral injury,” “the distress incurred when a person is unable to uphold their core values and beliefs.”
Originally used to describe soldiers’ response in war to violating their core beliefs, such as witnessing or participating in the injury or death of innocent children, moral injury is now recognized to affect health care providers who, through no fault of their own, cannot provide the care their patients need.
Wendy Dean and Simon Talbot, two medical doctors who founded Moral Injury of Healthcare LLC, suggest that moral injury reflects the true impact on health care providers of our current health care situation.
Dr. Marsha Linehan, a cognitive behavioral psychologist, describes a dialectic in which apparently contradictory ideas are both true. The combination, the synthesis, is wisdom.
“You are doing the best you can,” says Linehan, and, “you have to do better.”
And you are doing the best you can.
Archer further states, “As a physician, I and other health care professionals took an oath to do no harm. The Covid-19 pandemic challenged these vows, forcing many clinicians to provide suboptimal care due to resource limitations, staffing shortages,” and more.
Personally, it breaks my heart to say no to so many people in need. Even as alternative measures are implemented, such as providing additional group psychotherapy instead of individual psychotherapy services while, hopefully, new clinicians are recruited, or considering group medication follow-up, I feel that I am not fulfilling my obligation as a physician to do no harm.
Crisis management without ongoing care is not enough.
Beyond the strain of Covid’s impact on patients and colleagues, being unable to fully serve those in need wears me down. I think about cases that the clinic has referred elsewhere or put on an internal wait list. I worry about them when I am at home with my family. Some of them have no family. Or no home.
I remind myself: I need to do better. And I am doing the best I can.