To examine gaps in effective self-directed violence risk assessments by emergency medicine physicians. Four focus groups (N = 16 physicians) were conducted, followed by thematic analysis. Eight themes were identified in 1,293 coded passages. Participants discussed the practical ways they deal with the challenges of assessing and managing self-directed violence in low-resource settings. Emergency medicine physicians find mechanistic suicide screenings problematic, especially when intervention options are scarce; they find patient rapport, clinical experience, and corroboration from colleagues to be valuable in addressing the complex challenges of suicide risk assessment and management.