“Hi, welcome to our emergency room, what brings you in today?”
“I need to see a surgeon.”
“And why is that?”
“I need to get the microchips implanted in my brain removed.”
What is the role of a psychiatrist? Depending on who you ask, you’re likely to get many different answers. To help people. To make me feel better. To push pills. Population control. It’s a question I myself have struggled with time and time again throughout my career, and it would be a lie to tell you I knew the answer perfectly. In reality, a psychiatrist wears many hats, and many psychiatrists view their own roles quite differently, which is reflected in how they practice.
I was a wee-medical student in Ontario, Canada, working in the emergency department one summer. We had a gentleman come in and request to see a surgeon to remove microchips from his brain that he felt were responsible for broadcasting his thoughts to the public.
In Canada, when you go to the emergency department, the first physician to assess you would be an Emergency Medicine physician. The doctor I worked with that day, Dr. S, asked me to go see the gentleman.
When I met him, he was tall, skinny (certainly not emaciated), and appeared a little anxious. He was far from the most distressed patient I had ever met and was not agitated whatsoever. I asked him the usual battery of questions and he denied being suicidal or wanting to harm anyone. He simply kept coming back to these microchips. “When is the surgeon going to come?”
I finished my assessment and thanked the gentleman for his time. I explained to him that in my experience, what he was experiencing could be best explained by a condition called psychosis. And good news! Psychosis is a condition that responds to medicine, and we are able to arrange for him to see a psychiatrist today if he is interested.
“When is the surgeon going to come?”
I excitedly headed towards the nursing station to review with my supervisor, confident that my diagnosis was correct and that my plan was solid.
“So, what do you think?”
“I think the most likely diagnosis is psychosis, probably secondary to schizophrenia based on his presentation.”
“Excellent, I agree. What would you like to do?”
“Well, I think we should consult psychiatry, send some antipsychotic labs, call his fam-“
“Wait a minute. Does he want to see a psychiatrist?”
“No, he thinks he needs to see a surgeon.”
My preceptor smiled and asked for my reasoning for treatment, and I explained that the guy is psychotic, he needs treatment. She disagreed.
The patient was psychotic, this is true. He was not suicidal, he wasn’t violent. He wasn’t agitated, or emaciated. There was no real visible distress – certainly not close to the amount of distress involuntary admission to hospital and coercive treatment causes. And he didn’t want to see a psychiatrist. At the time, I was somewhat mystified at the idea of not treating someone with such profound symptoms that in all likelihood would have been at least somewhat amenable to treatment. I imagined this guy’s life coming together, all his problems solved with my little pill.
Today, I know better.
People are entitled to believe and feel what they want. I have no right to tell you how to feel or what to believe. Is believing you have microchips in your head so different than believing there is someone in the sky that created the earth in seven days? I’m not sure it is. What my job is, is to intervene at moments of risk. You can believe you have microchips in your head – if that becomes so intolerable you feel like you need to kill yourself, it is my duty to intervene and keep people safe. In the absence of risk, as the old adage goes in Newfoundland, more power to ya.
There is of course the argument about treating psychosis when it begins to impact people’s lives, but does not cause an immediate risk. Someone who gradually becomes homeless over time due to functional problems as a result of psychosis, for example. Think the guy talking to himself on the side of the street. Yes, these people would (likely) benefit from antipsychotic treatment, but only when it comes from their own free will. When medications are forced on people, they quit them the first chance they get.
So what is my job as a psychiatrist? To help. To be available. To sometimes intervene and violate free will when there is a risk of harm to someone. But not to tell you what to think, how to feel, or what to believe. That’s your own choice.
Editor’s Note: We did of course offer this gentleman ample follow up, and he politely refused everything we had to offer. What we find important here is making this gentleman feel safe when he comes to hospital so that when he does need us, he feels safe to come.
Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.