A disheveled mass perched on the emergency room gurney greets you, weathered and leathery browed.
“I feel like killing myself.”
You’ve seen Mr. H before. He comes in occasionally, usually at the end of the month, when his Social Security money runs out. He’s homeless, has no family to speak of, and his success in the community is tenuous, effectively measured by how many dollars of disability money he has saved. Occasionally he presents to the emergency room because he spends too much money on his vices, drugs and drinking, and he has nowhere else to go. Compounding his problems, it’s a chilly night, and it has been raining non-stop.
Alert eyes watch you, as looks of familiarity are exchanged. Despite what he tells you, he is eagerly eating a sandwich, appearing very comfortable on the rigid bed. He doesn’t appear upset or sad. Your 30 minute interview, besieged by multiple klaxon-like squeals of the pager and returning calls, reveals little in the way of acute medical or psychiatric crisis. The only statement you are able to take away at 2 a.m., your umpteenth hour of work that day, is, “I wouldn’t feel this way if I had a place to stay.”
As physicians and medical trainees we often find ourselves on the front line of a battle that none of us look forward to: assessing a patient whom you suspect is feigning a serious psychiatric condition. These moments seem to be rising in frequency, and their causes are complex.
Emergency room contacts are increasing due to continued difficulty accessing primary care services despite the Affordable Care Act. Homelessness remains a critical social dilemma in many metropolitan areas, with recent analyses estimating that over 500,000 are undomiciled nationally. Many of these individuals subsist in places meant not for habitation and utilize the emergency department at rates three times greater than housed individuals. San Diego, where we practice, has the fourth highest homeless population in the country. We routinely find that area shelters, crisis houses and sober living facilities are full, which leaves limited options for patients needing a safe place to sleep.
While homeless individuals do suffer from higher rates of mental health problems, including experiencing trauma, struggling with substance use issues, and being more vulnerable to other psychiatric illness, the acuity of their symptoms many times are not severe enough to warrant hospitalization in a health care system that is becoming increasingly strained.
As psychiatry residents, many of our consultations in the emergency department focus on assessing suicide risk in the undomiciled, and we appreciate these tensions first-hand. Many of those who we evaluate pose a low acute risk of self-harm, despite their chief complaint, eventually discharging to their own recognizance. On many occasions these patients leave the emergency department willingly, acknowledging in the end that they were not actually contemplating suicide, voicing suicidal ideation as a means to bring attention to their distress. Other times, this process is not so amicable, and is punctuated with verbal or physical escalation, and in rare cases, requires security personnel for escort off-premise.
No matter how it occurs, this type of resolution is profoundly dissatisfying for both clinician and patient. The clinician wonders how such an encounter could ever be therapeutic. The patient leaves without getting his needs met. Multiply these contacts by all of the call shifts during training and beyond and it adds up: compassion fatigue, burnout and secondary traumatic stress. Those at the point of care — emergency physicians, psychiatrists, primary care physicians — are most affected, but the ripple effects are system-wide.
How do we deal with these clinical situations? How ought we address the larger issues at hand?
There are no simple answers, and certainly no panacea.
At the most basic level, one solution is to change our approach — we may not be able to address the root cause, but we are able to act in meaningful ways during the encounter. We can allow these patients to be heard, acknowledge their struggles, and treat them with dignity. This simple change in mindset can not only help refocus us to the reason why many of us went into medicine, but also act as prophylaxis against being dismissive or cold to patients. This compassion, however, must also be linked with a frank discussion about the extent to which we can help these individuals gain housing or meet other needs. As physicians, we must have the humility to know our limitations and acknowledge that we are not able to solve many dilemmas in these acute moments of crisis. In the moment, we can only strive to provide the highest level of care to the best of our abilities and work within the confines of our larger health care system.
Another approach that can simultaneously benefit our patients while empowering us as physicians is to be more socially and politically active. Sharing our experiences of how systems fail our patients on social media, or in publications to raise general awareness — such as writing for in-House — as well as writing to local legislators and politicians is a powerful mechanism for change, underutilized by doctors. These activities may be the most useful to our patients in the long term, and may even be therapeutic for us.
Mr. H stayed in the emergency department for a few hours after the initial contact. Our social work team attempted placement at temporary housing, and the psychiatry consultant called several crisis houses in an attempt to discuss Mr. H’s case personally, to no avail. His risk for self-harm was judged be quite low based on his history, demographic information, and his behavior in the emergency department. As such, the psychiatry consultant, along with the emergency physician, informed Mr. H that he would be summarily discharged. Mr. H was frustrated and disappointed. On first blush, he expressed that all doctors were heartless and yelled, “You don’t care about me!” But after a few minutes, he was noted saying to other staff that, “At least I got a sandwich — it was too cold yesterday, I don’t think I would have made it if I wasn’t here, but there’s light out now…”
It was not pleasant to tell Mr. H that he was going to be leaving the emergency room, but there was some benefit from being out of the elements even for a few hours — both for the patient as well as for us. The sharing of Mr. H’s case in this public forum serves not only as a meaningful post script to his case, but, we hope, also helps readers consider their own thought process in similar situations.
These activities and mindset may not be enough to eliminate our weariness, but reframing the encounter to acknowledge what we can do can help us recover purpose, and importantly, make us better, more fulfilled doctors.
Author’s note: We thank Dr. Alana Iglewicz, Assistant Clinical Professor in Psychiatry and Associate Training Director of the Psychiatry Residency at University of California, San Diego, for thoughtful feedback and discussion in preparing this article.