Where Experts Are Many

Conversation 1

The resident handed me the phone. “The psych charge nurse thinks the patient should stay in the ICU,” he said.

I glanced at my watch. My outpatient clinic was in 15 minutes. We had had a hard time convincing the family and the patient about the need for psychiatric admission, and now this. I took a deep breath.

“Linda, how are you?” I said, in that cloyingly pleasant tone my voice takes on when I am trying to suppress irritation.

“Dr. Bhat, what an unfortunate case. We have to do whatever we can to take care of this young man. We have to do what’s right for him.” I didn’t say anything, and after a pause, she continued, “I am just concerned about him being transferred to psych.”


“You know, with that catheter in his chest.”

“He needs the catheter for dialysis, and he’s going to need it at least for the next 3 weeks. He’s medically stable, though, and obviously needs a psych admission. Are you concerned about nursing care for the cath

“No, we’ve taken care of Ash caths before. It’s just that. . . . What if he pulls it out while he’s here? I am not sure what we would do.”

“Look, he’s not actively suicidal right now, and he can’t stay on the medical ward or in the ICU for the next 3 weeks when what he needs is treatment for his depression. I don’t think there’s a danger of his pulling out the cath, but if he did, you could always call the rapid response team.

They’ll be there in less than 2 minutes.”

“It’s just that we haven’t had suicidal patients with Ash caths here before—”

“And in your opinion, this patient is actively suicidal?”

“No, well, I haven’t laid eyes on him, and of course, I am not questioning your clinical judgment—”

“I don’t mean to minimize your concerns, but as you said, you haven’t even seen the patient and I just spent an hour with him. I’m telling you that in my clinical opinion, he is better off being treated on the psych floor. Now, obviously, no one can guarantee that he won’t pull out the cath, but all things considered, the benefits far outweigh any risks.”

“I’m not so sure, but I guess if that’s what you want—”

“It’s what’s best for him.”

“Well, OK, but we are going to want to keep him on continuous observation.”

“That sounds reasonable. I’ll let the inpatient psychiatrist know.


Conversation 2

“I don’t think he has a bipolar disorder; I think it’s more like anxiety,”

Dr. Ahmed, the resident, said.

“Well, it’s true that sometimes anxiety can be misdiagnosed as hypomania, but tell me more. Why do you think it isn’t hypomania? What did you see on the mental status exam?”

“Oh, nothing that would make me think of bipolar.”

“What did you think of his speech?”

“Yes, it was a bit fast—”

“Was it pressured?”

“Maybe, a little bit pressured.”

“Dr. Ahmed, pressured speech is like pregnancy.

Either it is pressured or not. It can’t be a ‘little bit’ pressured.”

“In that case, yes. His speech was pressured.”

“What did you think of his thought process?”

“It was a bit tangential.” He saw the look on my face.

“OK, it was tangential.”

“Was he grandiose?”

“No, I don’t think he was grandiose.”

“What did he say about his academic abilities?”

“I don’t remember.”

“He said, ‘I was the smartest kid in school. I am very smart.’ Do you think that’s true?”

“Maybe; I am not sure.”

I sighed. “From the mental status exam, did you get a sense about his intelligence—did he seem average, below average, or unusually bright?”

“He was average, I think.”

“So, he’s overstating his abilities, which means that we are seeing an elevation in his self-esteem, consistent with hypomania, or narcissism. Anything else you noticed about him?”

“He said that his mood is anxious.”

“Well, what did he say exactly, Dr. Ahmed? He didn’t use the word ‘anxious’ did he?” I felt like a lawyer cross examining a particularly slippery witness.

“I think he said he was feeling some kind of ‘internal pressure,’ and in my experience, that sounds like anxiety.”

“It takes about 20 years of experience to say, ‘in my experience,’ Dr. Ahmed. Maybe this case will give you a different perspective. Now, the patient said, ‘I feel an internal pressure, like something in my body that wants to come out.’ That might be anxiety, but it’s also consistent with hypomania. What is his sleep like, did he say?”

“He said it was not good; he does not sleep well.”

“Correct. He said, ‘I can go days without sleep and still feel pretty good.’ So, although anxiety can explain some of his symptoms in isolation, if you put everything together—the decreased need for sleep and irritability, his pressured speech, the tangential thoughts, maybe some grandiosity—I would say the patient does have a bipolar disorder.”

“OK,” Dr. Ahmed said, then added, “But it could also be anxiety.”

Conversation 3

“I don’t think I’m depressed; my moods go up and down every day. I was reading up on it on the Internet, and I think I have bipolar with ADD.”

“Susan, you don’t have bipolar. Your mood does go up and down, but that’s because of your depression, anxiety, and your personality. You don’t have ADHD. Your concentration is off because of your mood. ADHD begins in childhood and—”

“I seen on TV that you can get ADD as an adult,” she interrupted.

“Adults who have ADHD have had it since they were kids. So, you cannot have ADHD as an adult, if you didn’t have it as a kid.”

“You don’t think I got ADD or bipolar then?”

“No, what you have is mainly anxiety and depression, and—”

“Well, you’re the doctor, but it sure sounds like bipolar to me.”

It had been a frustrating day, and I tried to relax for a few minutes in the doctors’ lounge with a cup of orange and spice tea, the kind that I usually associate with less strenuous times back  during my psychiatry residency in England. Dr. Fernandez, with his trademark scrubs and surgical cap, was eating a ham sandwich, and leafing through a newspaper.

 “Hey, how’s it going, Hector?”

 “Bueo. All good,” he replied, with a broad smile.

 I closed my eyes and wondered what it would be like if his specialty was more like mine. What would his day be like, if surgery were more like psychiatry?

Conversation 4

“Dr. Fernandez, are you the surgeon who operated on

Mr. Jones?”

“Si, yes, and you are?”

“I’m the nurse taking care of him. I notice that you made a horizontal incision and chose a retroperitoneal approach. I think you might want to consider a vertical incision, and avoid retroperitoneal dissections.”

Conversation 5

Dr. Fernandez examines the patient, looks at the CT scan, then pronounces, “As you can see, Ms. Wilson has acute appendicitis and needs an appendectomy.

The resident interjects, “In my experience, his symptoms are more like gastroenteritis, and I think the patient will be fine with some fluids.”

Conversation 6

“It looks like you have a direct inguinal hernia, Mr. Smith,” Dr. Fernandez says.

The patient replies, “Are you sure I don’t have an indirect inguinal hernia?”

“Where facts are few, experts are many.”

—Donald R. Gannon

November 24, 2018 | 10:51 am | By Dr Shyam Bhat
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