I am within a hair’s breadth of having closure on my psychiatry training. A mere 6 days, 144 hours, stand between me and the end. Somewhat disappointing is the fact I am beginning to feel a little like I know what I’m doing. Not terribly well, for I am no expert in this field by any stretch of the imagination. But I feel I have a fair grasp of the basics.
For a GP trainee there is only one key thing I actually need to take from this post, and it is an essential one to get right. I need to be able to distinguish between the patient who says they are going to attempt suicide and the one who actually will if I don’t intervene. The process of trying to determine this tricky task is called risk assessment. Nothing fancier than that. Which is somewhat surprising given that there is no science behind it, it is an art form with good communication skills at its heart.
Being in the last week of the job, there are all sorts of assessment hoops to jump through under various guises like case based discussions, clinical evaluation exercises, multi-source feedback and my consultant supervisors report. And what better way to demonstrate my competence than show I really have mastered my ABCs.
On the ward round my identified patient comes in. I start with the cursory preamble, a lead up to the main event. It’s immediately clear that he is a season ticket holder to the psychiatric ward. He knows what’s coming, he probably knows better than I do how this line of questioning plays out. Still, it is only good manners not to dive in feet first. I wouldn’t take too kindly to someone meeting me, and then ploughing straight in to my suicidal intent. So rather than denying him my best mundane chat of how his weekend has been, is he sleeping ok, how’s the food, I play the game. Obviously I do realise he’s an inpatient detained under the mental health act for his acute psychosis. I’m not hoping we’ll be bosom buddies at the end of the day but I do want an honest answer to my risk assessment – that is if I ever get round to it! So finally the time comes, his monosyllabic answers make it difficult even for me to fool myself an actual conversation is taking place. This being the two-way exchange of words that it is.
I wrap it up nicely in a flowery non-threatening way and toss the ball gently into his court, “have you had any thoughts of not wanting to be alive?”. Hmmm a clumsier delivery than intended. I use tact as my ally because heaven forbid I should put ideas into his head by going straight in for the “are you having any thoughts of suicide”. Apparently this doesn’t happen, you don’t transfer these thoughts to the patient. But 6 days, 144 hours off making any boo-boos I’m not about to start, assessment or no assessment. Of course we both knew this was coming, how I ask the question is probably a mute point. He’s heard it several times a day on this admission and we’re sadly multiple admissions down the line. He’s been asked this question a lot.
“You need two things to kill yourself” he replies, making eye contact for the first time during the review, “intent and motivation”. He’s right of course, I just hadn’t thought of it like this before. This is followed by a long pause, I’m hoping he’ll give me an answer to the question as I’m really not wanting to ask again. After what feels like an eternity, he obliges and takes his turn, “I just don’t have the motivation, I’m walking the line”. My thoughts immediately flit to Joaquin Phoenix playing Johnny Cash in the film of the same name, there must be a link…. Thankfully I’m spared making some tenuous link which doesn’t exist, “I’m on that line somewhere between happiness and sadness”.
We spend a while longer talking, he begins opening up a bit and is able to relax now all the heavy stuff has been covered. He is clever, his vocabulary immense and language tied up with riddles and idioms. He may be unwell but the conversation is linguistically rich, he is a fascinating man and it would be a great loss if he ever were to make attempts on his life.
He leaves the room with me feeling I have been wrapped in knots. I have the answer I need, he can guarantee his safety. And my assessment is complete, I have the thumbs up to go forth and practice psychiatry within primary care.