3 Visits to the Psychiatrist

A new psychiatrist on Substack joins our newsletter for a guest post!

One of my favorite episodes of House, M.D. of all time is “Three Stories.” It’s the story of Gregory House, M.D., the pain medicine-addicted genius diagnostician with a great TV show, teaching a class about his own leg infarction. I think it’s a work of genius, and that show deserves way more credit than it gets. Stories are a great way to teach and demystify what happens in a psychiatric visit. I’m thrilled to welcome a new guest to The Frontier Psychiatrists today!

Benjamin Lippmann, DO

is a board-certified psychiatrist practicing independently in Central Florida. The following is his first appearance in this newsletter. He takes us on a tour of three unique encounters with our imaginary psychiatrist. Dr. House, we got this one. — Owen.

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Encounter #1 — The best consult.

A psychiatrist is familiar with the taste of humble pie. Medical science has afforded most other specialties the illuminating light of ever-more-illuminating science in recent memory. For example, consider some of the pioneers of neurology. These are (nearly) household names—Charcot, Tourette, and Barré; they all lived in 19th-century France.

Medical science needs time to work out the basis of our psychiatric pathology, yet. Our current paradigm of psychiatry remains phenomenological. Imagine heart disease as a phenomenon: a constellation of symptoms that begins to seem to the cardiologist as if heart disease may be present. Perhaps taking one, two, or even a cocktail of drugs might help the heart feel better?

Every modern specialty had, for a season, a paradigm residing in the phenomenological realm. Psychiatrists, when we are being honest with ourselves, understand our profession is in its scientific puberty. It is a bit of an uncoordinated-gangly-goof. One diagnosis in particular, however, has the deep voice of an almost confident pathology. Because the voice still cracks and squeaks at unexpected moments, the diagnosis remains in the realm of the psychiatrist—all the better to butter my bread.

I am referring to catatonia. For a psychiatrist, catatonia consultation is a chance to put down the humble pie and instead walk on water. Naturally, the consultant does not always refer to the patient as catatonic. Even this ancient presentation is esoteric to many, both hospitalists and nurses. However, the clinical eye of the psychiatrist can identify it quickly.

The consult might sound like this: “Doctor, the patient barely eats and only mumbles a few words at a time. The patient has a sibling who says this began a few months ago and seems to be getting worse. We treated the infection, but the patient lays there staring at me. It’s weird. “What do you think it is?”

The psychiatrist will dutifully call the sibling, speak to the nurse, and meet the patient. Sure enough, the history and presentation are consistent with catatonia. Now, everyone, get ready because this is one of the few times an intervention in healthcare makes everyone weep.

“Medical Floor Nurse, I want you to do exactly what I say. You will not believe me at first, and other nurses might try to stop you and tell you I made a mistake, but you will see a “miracle” today. Get Ativan 2mg and push it through the IV. Wait for 10 minutes — stand there and watch. If nothing happens after 10 minutes, call me.”

Now, the psychiatrist, consulting to the internal medicine service, coolly walks away. It is all up to the nurse. She draws the medicine. The other nurses try to stop her, “Why would you give a sedative to someone so sedated-looking?” But she has never seen the psychiatrist deliver instructions so deliberately.

She draws up the medication. IV push. Timer. Nothing is happening. Was this a prank? Another minute.

5 minutes more.

It is almost 10 minutes now.

I guess that kooky psychiatrist was pulling her leg. The nurse turns to leave but hears a voice behind her. “Hello? Are you my nurse? I am famished; could you bring me something to eat?”

Everybody on the team and in the family weeps. Every time. And, for a few days, maybe even a few weeks, the psychiatrist can taste victory instead of the humiliation of helplessness in the face of human suffering. “Less humble” pie, anyone?

Encounter #2 — Finding God

Inpatient psychiatric units are sometimes compared to jails. The purpose of psychiatric confinement lacks the American prisons’ tradition of penitence. But the comparison? It is fair. The most persuasive argument in favor of involuntary hospitalization might not be what you expect:

Psychiatric illness holds the patient captive while removing all quality of life.

Am I signing off on holding the patient captive in a building and administering malicious chemicals? Yes, with a proviso. It is an opportunity to achieve liberation from the worst imaginable torments. Only once did a public defender successfully argue for my patient to be released from the legal hold before I could liberate the patient from the illness, and I told that public defender the truth: “When the patient comes back, I will try again because you didn’t help him.”

In this case, at least, I was proved correct in less than a week — perhaps the fates rewarded my arrogance? Psychiatrists become so comfortable in court hearings because most states require sworn professional testimony before a magistrate or a judge to proceed with involuntary hospitalization beyond a few days. This translates into weekly court hearings. Often, the court dispatches directly to the hospital psychiatric unit. Some patients will mutter an utterance or so in regard to the writ of habeas corpus. I, personally, never observed any better outcome for these patients other than signaling to a judge their numerous prior hospitalizations. I do not hold it against anyone to want to be released as soon as possible, but mentioning habeas corpus tends to backfire. It led to an extra dose of bureaucracy. Treatment interventions delayed are not better.

I once met an “involuntary patient” who read aloud a paragraph from a loose sheet of paper. The reading was all legalese. She finished reading the… spell? She watched me expectantly. I felt terrible for the patient because she sincerely believed Merlin’s Brother, somehow a Lawyer, had revealed the secret of pulling the sword from the stone. Of course, the chanted words were unlikely to result in a sudden change in my clinical judgment.

Did you know, dear reader, that there is an entire religion that is anti-psychiatry? This religious organization sends out hate mail, pickets conferences, and uses unkind nicknames for psychiatrists. They have a well-known museum with a dramatic name in Los Angeles depicting psychiatrists as evil. If an outspoken physician or researcher is decidedly anti-psychiatry, there is a good chance this organization will provide financial support for the anti-psychiatry message. Their leader declared war in 1966.

Fortunately, it is a war of ideas and not of terroristic threats. [Redacted Faith], thank you for providing this unique characteristic of psychiatry. Is there any other religious organization that wars against a single medical specialty?

Our psychiatric patients suffer. They deserve healers with the faith that their pain, no matter how perplexing, is worth ameliorating.

Encounter #3 — The Devil Went Down to The Unit

Mental illness is a vulnerability multiplier. The psychiatrist poses more risk to the patient than vice versa most of the time. However, those exceptions can be life-threatening and terrifying.

Psychiatrists make up about 5% of physicians but are the specialty most likely to be the victims of homicide. Approximately 28% of physician homicides are psychiatrists.

The overall number of physician homicides is small, thankfully, and is not worth spending much mental energy on. Being struck, bitten, choked, or battered with bodily fluids, however, is much more common. I experienced a grapple about once every other year while working as an inpatient. Verbal redirection of a patient is implausible once a grapple begins — it can be a struggle for one’s life.

Inpatient units have teams and protocols for this. The office-based outpatient setting has fewer effective strategies available — psychiatrist homicides tend to occur in the office. Violence is dramatic, sudden, unpredictable, and destructive. The emotions following an encounter with violence include fear, guilt, shame, despair, and anger. So, how does this pertain to patients?

A young man in the midst of a first psychotic break was not responsive to verbal redirection as he repeatedly kicked hard against an emergency exit door. The door withstood the onslaught, but the staff needed to de-escalate the behavior. The staff activated a security response protocol. In the background, about a year prior, the same hospital security officers witnessed an officer be seriously harmed by a violent inpatient encounter, resulting in the loss of the officer’s eye.

This tragic outcome led to some radical unofficial policies of “escalation.” These unofficial policies were hidden from view, the justification existing only in the minds of a few. These were the people on duty on a Saturday afternoon. Instead of a typical quiet weekend, I hurried back to the hospital after receiving a frantic message: “Your patient needs to be discharged to jail.”

When I arrived, the patient confronted me in handcuffs, hyperventilating and foaming. A police officer (gun holstered on the hip) was standing behind the patient. A nurse cursed loudly, and a security officer scowled. Everyone there, including the patient, had decided the outcome without me — the young man was going to jail, and all that was left was for me to sign the order. There had been a scuffle.

The only person who seemed calm was the police officer. Recall that, usually, firearms cannot be brought into a locked behavioral health unit. Even he had a secret protocol, which he followed. Who was going to help the patient?

What would you have done?

There is no special training for chaos. Each person needed something from the doctor—oh, that was me!

I chose, in this “composite” scenario, to act on principles mixed with intuition. I worked to slow everything down. I took a curious stance. “What is going on?!?”

It helped me to be genuinely confused about what, exactly, had happened. I made it my mission to talk to everyone and absorb the swirling anger, knowing it is okay to be upset. Anger, at least, is not a crime. Maybe jail is safer for the patient right now? Risk calculations clicked off in my head. This untreated psychosis is dangerous, but another incident with this staff is looking deadly—we had limited resources in a poor rural hospital.

I signed the order. There was a relief of tension. What followed were apologies for the mocking, apologies for the cursing, apologies for the firearm, and apologies for kicking the door. The patient even seemed relieved. Hospital administration could sort out why secret protocols were followed instead of the written ones. Autonomy versus paternalism is a needle to be threaded. All professions have their dirty work — that day, it was not pretty to see how the sausage was made. The weight of that decision was heavy, and there are dozens of actual decisions behind this one fictionalized vignette.

We are asked to stand between the patient and the venom the world often has for people suffering from psychiatric illness. We are not magicians ourselves. Every day, we fail and try again. These fraught circumstances allow us to advocate for beneficence, yet always with a Faustian bargain baked in. We are forced to weigh the possible against the perfect.

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Join me in thanking Dr. Lippmann for writing this extraordinary series of stories on short notice! He writes at:

This newsletter’s author is also the author of Inessential Pharmacology. My fellow Substack stalwart

Awais Aftab

also has a book out! Conversations in Critical Psychiatry is available now!

Those are Amazon affiliate links that support the work here.