“It breaks my heart to say no to so many in need” – New Hampshire Bulletin

A friend contacted me about her adult daughter who had lost her job, was drinking and was contemplating suicide. I have carefully considered what services my friend’s daughter should receive to help her recover.

As physicians, we are trained to serve those in need and at least do no harm. My friend and her daughter had contacted several private psychiatrists who all said they had no place for a new patient.

In contrast, in community care, the expectation is to maintain an open door and serve the community, including the underserved who cannot find care elsewhere. In short, everyone in need.

The community mental health clinic, currently exhausted of therapists, community support specialists, supported employment specialists and most other staff, cannot serve all those in need of care.

Knowing that, I tell my friend no. At the moment the clinic does not have the resources to help your daughter. If she is in immediate danger, take her to the emergency room or call a crisis hotline. don’t let her die

Unfortunately, the lifesaver of community care is itself in need of rescue.

Another: A 25-year-old young man feels depressed and hopeless and has no job. When stressed, he cuts his arm to watch it bleed.

When he calls the clinic, the admissions specialist carefully considers his situation. Can the clinic serve him? no The clinic is not staffed at this time to provide him with the care he needs. We offer alternatives. Please call your family doctor. Go to the emergency room, call the mobile crisis management team or call a crisis hotline if necessary. Do not give up.

“No” is a common response in medical care today, well beyond psychiatry. A college student is told that new regulations mean he can no longer get his tetrabenazine to treat muscle spasms, even though it was a life-saving drug for him – not in terms of life quantity, but in terms of quality. How would this patient’s life be different if he had unpredictable, disfiguring facial twitches, maybe even random vocal explosions?

Another patient is told that cataract surgery cannot be scheduled for a year due to the shortage of ophthalmologists. Twelve months of blurred vision.

And try to find a GP if you don’t have one. The answer is no.” Wait. Wait longer. I hope you don’t need medical attention.

Today, every medical provider I know is doing their best to stay emotionally afloat—with too few resources, too many patients, and more potential patients in the dock waiting to come on board. Too few doctors. Too few nurses. Too few therapists, phlebotomists, social workers, case managers, professionals in all areas of healthcare.

Two state psychiatric clinics had to close temporarily due to a lack of care. Many of the medical/surgical nurses at a local hospital are traveling nurses, without whom these units may also have to consider temporary closure – an unacceptable option.

Fortunately, people in immediate need turn to mobile crisis teams, emergency centers, emergency rooms, which do their best to provide stabilization. Thank god for these services. In contrast, people who need ongoing care because of chronic illnesses have trouble finding it. When they seek help, most of the time the answer is no.

We know how this situation endangers the health of people in need of care. But what about the impact on healthcare providers?

In a recent comment, Dr. Christian Anthony Archer describes the emotional distress of this situation for healthcare providers as “moral injury” – “the suffering that results when a person is unable to uphold their core values ​​and beliefs.”

Originally used to describe the reaction of soldiers in war to violations of their core beliefs, such as B. witnessing or participating in the injury or death of innocent children, it is now recognized that moral injury affects healthcare providers who, through no fault of their own, cannot provide the care their patients need. dr Wendy Dean and Simon Talbot, founders of Moral Injury of Healthcare, LLC, propose that moral injuries reflect the true impact of our current health situation on healthcare providers.

dr Marsha Linehan, a cognitive-behavioural psychologist, describes a dialectic in which seemingly contradictory ideas are both true. The combination, the synthesis, is wisdom.

“You’re doing your best,” says Linehan, “you have to do better.”

And you’re doing the best you can.

Archer goes on to explain, “As a doctor, I and other healthcare professionals have taken an oath not to do harm. The COVID-19 pandemic challenged those vows, forcing many clinicians to provide suboptimal care due to resource constraints, staffing shortages, and more.”

Personally, it breaks my heart to say no to so many people in need. Even if alternative measures are implemented, e.g. B. offering additional group psychotherapy instead of individual psychotherapy services while hopefully recruiting new clinicians, or considering follow-up with group medication, I feel like I’m failing in my duty as a physician to do no harm.

Crisis management without ongoing support is not enough.

Aside from the burden of the impact of COVID on patients and colleagues, I am unnerved by the fact that I cannot fully serve those in need. I’m thinking of cases that the clinic has referred elsewhere or put on an internal waiting list. I worry about her when I’m at home with my family. Some of them have no family. Or no home.

I remember: I have to do better. And I’m doing my best.

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