How we think about Primary Care "Gatekeepers"

Primary care physicians are often grouped in as "gatekeepers," who need to be able to ask about suicide, know warning signs, and refer. The tend not to get in-depth training about formulating or documenting risk assessments.

The problem with this "gatekeeper" view is that we don't have the kind of seamless system that allows the primary care professional the luxury to leave the judgment call to a mental health professional. It's not like they are standing at a gate, able to wave a patient on to a mental health professional on the other side. There are barriers to access, patients who refuse evaluations, and the need to make decisions about who warrants intrusive involvement and who does not. These are sophisticated clinical judgments that go beyond "know the warning signs." PCPs have to be able to articulate an evidence-based rationale for allowing a patient to go home with an outpatient appointment versus involving a psychiatric emergency team.

I met with a group of pediatric primary care professionals this week. Our discussion brought this point home to me. They were eager to be trained in true risk formulation and documentation--and felt that these skills would help them feel less anxious about asking about suicide.

There may be some gatekeepers for whom instruction in questions, warning signs, and referral options is enough. But primary care gatekeepers need more.