Something Intuitive

A gut feeling. Sometimes this is all I can say when I meet a patient. Yet I know that my brain is processing millions of information from the patient’s unspoken language. From the way the patient carries herself walking into the room, sitting down at the edge of her seat, shifting her position, and pulling her hair back but keeping her eyes down. Then when she finally decides she is in a safe enough place to make eye contact, you see the pain. It’s not really just an intuitive thing. It’s a million, gazillion sensory informations that get processed in my head in a milisecond. Like the way her eyes dart quickly around the room then settles, and how the lines around her eyes deepen just a tiny bit. I can’t describe it all, but it’s as if my brain processes all those pieces of information without my conscious awareness.

I wish there was more verbiage we could use to described non-verbal language in psychiatry. It would really add to the objectivity of our mental status exam if we were trained to describe in more detail these fleeting looks of despair and agony.

Throughout my own research into suicidality, it became clear to me that it is much more important to pay attention to what the patient does not say than what he or she actually says. They might deny feeling hopeless, entrapped, and suicidal, but if the facts do not make sense and the body language seems concerning, then it might be time for emergent and inpatient level of care. But is it though?

The insurance companies do not like this proposition. You are admitting someone to an inpatient psychiatric unit because of a gut feeling? And the patient is denying everything? I get their point of view though, because it really becomes an ethical question. Do you think you are THAT good, that you know what the patient needs before he/she does him/herself? Do you think you can really predict the future?

My attending told me something very interesting the other day. He said that ethics is not learned through books, articles, journals, etc. Ethic is learned through your own experiences, and how you decide to handle the ethical issues that arise based on your values. You learn ethics by having to choose your side.

All this is to say, that psychiatry can never really have “a criteria” for emergent help. The very nature of this field demands a personalized approach because no two humans are alike. You can’t rely on a list of symptoms on a checklist that you can mark off when a patient admits to it, or a vague description of their body language and demeanor. This is very unsettling to a psychiatry trainee like myself. I am never really sure if I am doing the right thing. In medicine, you know you made the right decision because the guidelines tell you exactly what to do. In psychiatry, all I can do is try my best to balance beneficence and patient autonomy. I guess this is part of why I love psychiatry, because each story is so unique, but it is also something that holds me back and keeps me awake at night. Did I really help that patient? Did I enable him by admitting him to the hospital again? Did I miss something and discharge the patient even though he really needed more acute level of care? I guess only time and experience will tell.