A woman recently requested a medication evaluation at the suggestion of her psychotherapist. The caller told me her diagnosis was borderline personality disorder. She hoped medication might ease her anxiety. She also admitted that two other psychiatrists refused to see her because she was too “high risk.” I asked if she was suicidal. Yes, thoughts crossed her mind. However, she never acted on them, and was not suicidal currently. I was curious whether my colleagues recoiled at the caller’s diagnosis, her suicide risk, her wish for anxiety-relieving medication, or something else.
By definition, “high risk” medical and surgical patients face an increased chance of poor outcome. According to a British study, high-risk surgical patients are a 12% minority who suffer 80% of all perioperative deaths. High-risk pregnancies threaten the health or life of the mother or fetus; they constitute six to eight percent of all pregnancies. Various charts and algorithms identify the high-risk cardiac patient.
Historically, physicians and surgeons accepted high-risk cases. As one would expect, these patients had poorer outcomes and higher mortality. Doctors did the best they could, humbled by their limitations and occasional failures, spurred to treat the next such patient more successfully. However, recent social changes conspire to blunt this acceptance. Fear of lawsuits, stemming both from an active medical malpractice bar and patients’ high expectations, means that doctors, too, are at high risk. Increased reliance on outcome data and online reviews by patients may likewise lead some clinicians to cherry-pick cases that won’t mar their results. Patients at high medical or surgical risk now have a harder time finding a doctor who will see them.
No single hazard defines the high-risk psychiatric patient. There is a robust literature on young people at high (and “ultra-high“) risk for developing psychosis. There are well established risk factors for addiction. Patients have also been deemed at high risk psychiatrically when they leave institutional care without permission; when they are young unemployed women following discharge from medical ICUs; and when they are youths with “serious emotional disturbance” who receive public services. Having a psychiatric problem at all may be one factor among many that signals high risk in non-psychiatric medical settings.
However, “high risk” in…