Midweek Medicine: Saying “No”

Many times I’ve been struck by the incredible (to my mind) ability of “boutique” teams/services to say “no”: to close the doors of their service and not accept new referrals – because of low staffing, and/or high patient load.

Boutique?

First, what do I mean by “boutique”? I’ll explain by contrast with the teams in which I have worked for all my time as a consultant psychiatrist, and most of my time as a registrar (psychiatrist in training): adult general psychiatry teams (often acute – inpatient or outpatient). We basically take all-comers. If someone clearly has no psychiatric illness we won’t continue with them once we’ve determined that, but other than that, pretty much that’s it. Given that adults (18-64, give or take) make up the largest chunk of our society, and that many of the illnesses we deal with come on in late adolescence, and carry a marked reduction in longevity (twenty years life lost, give or take about 5), and you will see that the bulk of psychiatric morbidity is found in the adult population. Thus the core of any psychiatric service is adult general psychiatry.

Around that core we have a number of other teams: age-based for example (psychogeriatric, child/adolescent), or other sub-specialty teams such as maternal mental health, or therapy teams, or culturally-based… and so on. Because these teams are based on a particular criterion or criteria over and above the basic “having a psychiatric illness” thing, they have an instant ability to refuse a chunk of inward referrals.

Now I don’t really have a problem with that in essence (I’d hardly think a child/adolescent team or a psychogeriatric team ought to see a 30 year old, for instance) I note time and again how some of these teams manage to close their doors even to people who meet their criteria, but for example the service is too stretched (as though the general adult core service isn’t…), or the patient poses ‘too much’ risk of harm to themself or to others, or the patient has a history of being ‘hard to engage’, or similar.

My contention is that working in the public service, we have to do what no-one else can or will: we are duty-bound to do our utmost to provide the best care practicable to those who are the most ill, the most risky, the hardest to engage, the least adherent …

… The most in need.

I do not think that in the public health service we have the luxury of picking and choosing with whom we will work. We do not have the luxury of seeing only those people who want our help, do what we ask, and have mild to moderate illness that responds well, prompting much gratitude and such. We are duty-bound to do the hard stuf that the private sector both cannot and will not do.

It’s hard work, the rewards of which are not simple: we don’t tend to get Christmas cards and bottles of wine from patients who have managed to “find themselves” Where satisfaction is to be found is in the doing: in the virtuous striving to deliver excellent care to the people who need it most. I guess that’s not an obvious sort of reward, but it is a real one. – And if it’s not enough for a practitioner in the public service, rather than saying no to the hard stuff, they need to get the hell out and work in the private sector, where patients come because they want to, and they can say no to the hard stuff … referring the patient on, inevitably, to the public sector.

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Tags: medicine, psychiatry, referral, saying no, service, turf