March 11, 2008

Suicidal Patients' Access To Their Psychiatrist

In the tradition of Robert Kagan and the folks at Policy Review, Robert Simon, MD defines foreign policy for the next century.

Robert Simon, MD is one of the big forensic psychiatrists in the country, along with Park Dietz, Robert Sadoff, etc.  In many ways, he sets standards of forensic practice.  He frames the debates: he (and others) decide what words we'll use, what principles are in vogue, how clinical data are applied in a legal context.

Which is why his latest article, "Suicidal Patients' Access To Their Psychiatrists" is-- no other way to say it-- a disaster for psychiatry.

His article can be summarized by the large red font excerpt in the middle of the page:

Standard of care requires that psychiatrists or their designees be accessible to suicidal patients and that they respond within a reasonable time.
He gives examples of what he feels constitutes standard of care practice:

In solo practice, the psychiatrist or covering clinician must be accessible 24 hours a day, 7 days a week, by cell phone, pager...Twenty-four hour coverage for patient emergencies is an established... standard of care.

First, I'll go on record and say that I think he is wrong.

On a simple level, the problem with the article is that he does not distinguish between "standard of care" and "best care."

Standard of care is defined in many ways, but here are two good ones: "customary practice" or "reasonably prudent similar health care provider."   They're not the same.  "Reasonably prudent" is not based on number of docs doing it.  Even if 99% of docs are doing X, it could still be substandard care.   Which is, in effect, what he is saying: whether or not most psychiatrists do this is irrelevant-- they should do it.

So the trick is this: in the guild system (yes, like a thieves' guild) of medicine, who decides what the standard is?  What a "reasonably prudent" doctor would do?  In some cases, it's obvious (e.g. no sleeping with patients no matter how hot they are) but ultimately the answer is there is no answer:  it's decided in court, in a duel between experts.  And academic articles are the ammunition. 

So while I disagree with him on what is standard of care, the real problem with the article is more serious:  by writing this article, Simon isn't merely reporting the standard of care, he is causing this to be the standard of care.


Believe it or not, I am not completely without empathy for other people.

I recognize the feeling of crisis, of vertigo-- nausea-- that some have when their bodies and their minds tell them they have to GO NOW-- or, for others, that it's simply better and easier (just) to go...

That is a structural problem, a logistic problem, for psychiatry: how can we deliver effective and efficient care to those who, almost by definition, need us when we are not available?  This can be solved with outcome studies, with data, with debate.

But the issue right here is that this discussion has been effectively commandeered by Simon, and others-- others, BTW, who do not actually treat any patients in crisis. No one asked a regular psychiatrist; no one did a survey of the exiting practices.  He just said it.

He may be right that this should be standard of care, but he should have to defend his position. (For example: Is it true that the suicide rate is lower when there is 24 hour access?)

But by writing this, he's not asked to defend why he's right-- he just established the default position. The onus is now on everyone else to explain why he might be wrong.  The analogy is, well, Iraq: what happens when others in government-- who have never seen a war, let alone fought one-- tell you how and when to conduct a war? 

You're nodding?  Don't, because here's the answer: they get voted back into office, again.    Policy is always set by those with little direct investment in it; because those who have most to gain or lose have so little time, and so little access to the debate itself, that inertia takes over.


I don't blame Simon, and no, I don't blame Bush either.  It's not exactly their fault.  They are repeatedly given mandates to decide policy, and so they decide based on their principles (yes, Bush, too.)  They believe they're right-- and no one is around to tell them they're not.

Simon thinks he's right; and, for support, he offers the "top" psychiatrists-- academics.  Who, of course, don't have to deal with 24 hour coverage, either.

You can't tell Dr. Simon that 24 hour coverage is physically impossible.  For a solo practitioner with 100 patients, if 1% have a crisis, he's dealing with 1 phone call.   In a city, community mental health clinics treat 3000-10000 patients.  If 1% have a crisis, that clinic closes.   In states like Idaho, where there is one psychiatrist for a gigantic area-- sometimes even one NP who travels-- it's impossible.

But much more importantly, you would be scared to tell him he's wrong.  You can write a letter to the Psychiatric Times and say, yo playa, you're wrong-- but what's the point?  His article is in pubmed, yours isn't.  But you sure as hell wouldn't dare to tell him that within a mile of a courthouse.  "Dr. Simon is wrong, no community clinic in the Inland Empire does that."   Oh?   You just abandon your suicidal patients to the night and city streets?  Let the drug dealers and roaches care for them in a crisis?  Maybe the care in the Inland Empire isn't very good?  According to Dr. Simon, it's standard practice everywhere else.  Perhaps you should stop torturing your patients with your incompetence?

So you nod your head in assent in public, but stay quiet, hoping no one will ever scrutinize your practice.


Simon's logorrhea has a side effect: he's changing social policy.  I know he doesn't mean to, I know he would deny it, but it's true.

This is how it goes: the Law looks to Psychiatry to shed light on behavior.  Society watches this interaction and adapts.

Simon makes a specific point that leaving a "if this is an emergency, go to your nearest ER" outgoing message is not acceptable.  But then why is it for primary care?  If you have a heart attack at 2am, can you sue your doctor because he wasn't available and you didn't know you had to go to an ER?  Society hears him, and it says, "oh, people with psychiatric disorders are out of control.  They need 24 hour coverage." 

Forensic psychiatrists have massive power, they decide how psychiatry is applied to the law, to the public.  They make things true, not least because no one checks their work (except possibly the other expert.)  And Society has little reason not to accept it.

So Society infers: psych patients can't think clearly. They cannot be responsible for themselves, even when they're doing fine, because they might suddenly not be fine-- so  someone has to be there around the clock to catch them. 

And another steel I-beam is riveted to the infrastructure of a custodial society.