A topic that I believe is well suited for The Workbook is suicide. What if we didn’t do anything about suicide? (I won’t even elaborate on what I mean by that, mainly because I’m not sure what all I mean by that.)

I am, however, intimidated by the complexity of this subject. My line of work, after all, is that of a psychiatrist, and not that of an ethicist.

(But isn’t that interesting in of itself? Should psychiatrists receive more training in ethics? And, no, I’m not referring to the sticky relationships some psychiatrists have had with pharmaceutical companies. Nor am I referring to the few psychiatrists who abuse their patients. As it stands, most other medical services usually end up consulting psychiatrists for some ethical quandaries, like the decisional capacity of selected patients to make medical decisions or to participate in disposition planning. Furthermore, psychiatrists often play roles in involuntarily detaining people—no one ever told me that society would expect me to take away the civil liberties of my fellow citizens. Doesn’t that alone constitute a need for more ethics training?)

(And, just to be clear, I was fortunate to train in a program where we spent a lot of time discussing this. Hence my exposure to Foucault and Szasz.)

So, instead of dwelling upon self-inflicted death and all the complexities that precede and follow suicide, I shall focus on something with a higher prevalence: Suffering.

People suffer. Sometimes people suffer in solitude. Sometimes people suffer and share their suffering with others. Sometimes those others will suggest to (or coerce or whatever) the suffering person that s/he should see a psychiatrist.

I don’t know how many people willingly see psychiatrists. (I’m wandering off topic again.) I never see the people who adamantly don’t want to see a psychiatrist: they get up and leave the room the moment they learn of my profession. Which is fine: It’s not “right” or fair to deceive someone into visiting a “doctor” when, by “doctor”, you mean “psychiatrist”. In the hospital setting, most patients who were not expecting a visit from a psychiatrist (e.g. on a medical floor) are generally civil upon learning that the shrink has arrived. Do not be mistaken: I’ve received an earful a couple of times from patients who were frankly offended that their medical doctors did not tell them that a psychiatrist would be coming along. Which is also fine… and, ultimately, the referring physician gets a (gentle) earful from the psychiatrist and a (not so gentle) earful from the patient. Hopefully that experience is instructive in of itself.

Psychiatrists may be the last batch of physicians who are still granted a luxurious amount of time with patients. The standard appointment length for an initial evaluation is 45 minutes. Follow-up appointments are 20 to 30 minutes. The follow-ups can be squeezed down to 12 to 15 minutes for “straight-forward” medication management. (Another topic for another day.) And if someone is engaging in psychotherapy, that could be a bountiful 50 minutes a session!

Compare this to the underappreciated workhorses of medicine, the primary care physicians working in clinics. I still don’t know how they manage to get through patient appointments in their 7 to 10 minutes. The content of the appointments, however, is different.

Why do appointment lengths matter? Because most people find it difficult to express their suffering in 7 to 10 minutes.

Some people find it difficult to express their suffering in 50 minutes.

Not to say that the sole point of long appointments is to facilitate the expression of suffering. Without getting into the theory and function of psychotherapy (other writers with much more experience and greater eloquence have expounded on this topic), it should ideally help transform the individual to reduce or better manage the suffering. Psychiatrists should help people get “better”, a concept that is ultimately individually defined.

There was a time, and really not that long ago, that all physicians were in the business of helping individuals reduce or better manage their suffering. We didn’t always have antibiotics, inhalers, pacemakers, and metal rods and pins. We have amazing technology now that can make “cure” a reality. In the past, we might have been able to help patients “heal” and, failing that, we could “only” offer “comfort”.

Now that “cure” is possible in several different fields (think the procedure-heavy specialties: orthopedic surgery, gastroenterology, etc.), “suffering” can be like the gigantic zit on an otherwise clear complexion. It just “shouldn’t” be there.

The doctors we admire the most—the ones that patients love, the ones that medical students and residents want to emulate, the ones that earn the greatest respect from the public—are the ones who offer compassion and remain present when the suffering will not cease. When “cure” is nowhere to be found and “healing” may not be within reach today, we all hope that someone will remain with us in spite of our suffering. Something in that relationship—whatever that “something” is—is “healing” in of itself and can be the powerful force that reduces suffering… or helps someone better manage it.

(Yes, that phrase is apparently the refrain.)

Some psychiatrists have expressed umbrage with other doctors when these other physicians “turf” their suffering patients to us. A (stereo)typical example:

A man has belly pain. It gets worse. He tries changing his diet, drinking more fluids, taking over-the-counter antacids. He eventually sees his primary care physician, who uses the sparse few minutes she has to do a workup. Imaging studies are done. There’s a mass in the man’s belly. The man is referred to a surgeon. The surgeon believes that the entire mass can be removed. The man agrees to surgery. Everyone is optimistic. The surgery happens. Upon seeing the mass spread throughout the man’s belly, the surgeons realize that the man probably has a metastatic cancer and that his prognosis is poor. They stop the surgery. The man returns to his hospital bed. He wakes up. The surgeons tell him that he likely has cancer. The man is upset. The surgeons call the psychiatrists because “the man is upset—please evaluate for depression”.

It is within the realm of normal for a man to feel upset upon learning the news that he probably has metastatic cancer. It is also within the realm of normal for people to avoid other people who are suffering. It’s uncomfortable. People don’t know what to do.

• What should I say?
• There’s nothing I can do now.
• I’m powerless and I can’t help this man.
• I’m going to feel really bummed out if I have to listen to this man mourn the loss of his former good health.

etc.

Thus, it is understandable why the surgeons call the psychiatrists. They are passing along the hot potato. There is also the belief that psychiatrists are “better” (more skilled?) at comforting people. (That is one of the “jokes” that medical students hear: “You’re too nice to be a surgeon—you should be a psychiatrist!” Or, alternatively, “You’re too smart to be a psychiatrist—you should be a surgeon!” Or, as my internist colleagues may prefer: “You’re too smart to be a psychiatrist—you should go into internal medicine!”)

However, it is entirely unfair to both the patient and the psychiatrist for the surgeon to completely emotionally “turf” the patient. At its worst, the surgeons will rely wholly on the psychiatrist to speak with the patient about all the uncomfortable things related to the new diagnosis. The surgeon will only speak about the procedure itself: Is the wound healing properly? has the patient resumed eating? can the patient walk?

All of which are important, of course, but it is not fair for surgeons to ask the psychiatrists to have this doctor-patient relationship for them. As one of my colleagues once bitterly remarked, “This person is your patient, too.”

I’m not saying that it’s easy to sit with the suffering. It’s not. Especially when you’ve got other patients to see, paperwork to do, random things to take care of, and whatever else is piling on your plate. And, yes, it is true that psychiatrists do receive specialized training in listening, observation, and psychological interventions. Empathy and actually “being” with a person, though, are skills that all physicians should not only have, but should actively exercise!

Often, these referrals to psychiatrists are not actually messages that something is “wrong” with the patient. Sometimes they are actually reflections that the referring physician does not believe that he has the skills to adequately help the patient. That’s fine—I’m going to refer a patient to a(n orthopedic) surgeon if he’s mangled his arm and fractured his bone somehow… but not before I do a cursory exam, obtain X-rays, draw some labs, and irrigate the wound.

And perhaps we psychiatrists should be doing more to help our colleagues manage suffering. Physicians suffer when their patients suffer. Some physicians believe that they have failed; some mourn mortality; some grieve the loss of a patient that they knew well. Given our training and expertise, we are in excellent roles to (1) teach other physicians how to offer empathy and support for people who are suffering (step 1: don’t run away) and (2) provide support and empathy for our fellow physicians, who often see terrible things happen to a variety of people, day in and day out.

We psychiatrists should help our colleagues reduce their suffering or help them better manage it (if they want it—”I’m fine, I don’t need a shrink”). Ah ha—physician, heal thyself, right?

I’m not going to go into the whole healthcare reform issue—I don’t have anything novel to say about it. There are much more brilliant people who make intelligent remarks about it elsewhere. However, I will say that it is unfortunate that the system does not grant physicians time to spend with patients… or reward them for doing so. When doctors are harried, they can’t take the time to get a more thorough history, perform a more detailed exam, or be with the patient. These are all important aspects of healthcare… be that curing, healing, or comforting.

I have no data to support the following assertion, but here’s an anecdotal observation: If we are not generous with our resources—be that time, money, compassion, empathy—with others, it is difficult for those others to extend those same resources back.

(It appears that I ended up writing about time instead of suffering. This is how you can tell that I’m not writing off of a structured outline.)

(Part of The Workbook Series.)