At a recent morning rounds, a resident presented a case of a do-not-resuscitate decision for an elderly patient, which our psychiatry consultation service received overnight from an internal medicine ward. Another resident casually mentioned how physicians from other services at our hospital habitually call on psychiatrists to “make the difficult ethical decisions for them.”
That got me thinking. Psychiatrists are expected to analyze conflicts, resolve dilemmas, exercise good judgment, provide advice to colleagues and patients, and display a transcendent and objective perspective about the complexities of life. Psychiatric training and practice prompt us to be thoughtful, tolerant of ambiguity, and willing to tackle the multilayered meanings and consequences of human behavior. Indeed, developing attributes related to the most advanced functions of the human mind is at the core of our professional training and clinical practice.
Medical specialties develop different skills
Consider the training consequences of other medical specialties: surgeons become adept at navigating structural anatomy with superb dexterity to extricate lesions, repair wounds, or transplant organs; radiologists excel at scanning complex black and white patterns in radiographic images to detect the subtlest pathologies or anomalies; pathologists pinpoint cause of death with autopsies and elegant tissue examinations; and obstetricians become virtuosos of birthing or repairing intricate reproductive structures.
We psychiatrists go well beyond the standard medical history, physical exam, and laboratory findings. Our major skills are detecting gross and minute deviations in the mental status exam and the range and nuances of patients’ behaviors, insight, judgment, cognition, coping skills, internal conflicts, drives, compulsions, thought processes, personality traits, decision-making, resilience, social skills, interpersonal adroitness, truthfulness, emotiveness, impulsivity, ambition, perceptions, perceptiveness, verbal and nonverbal communications, defense mechanisms, and outlook on life.
We also integrate our complex observations and findings with the rich collage of each patient’s unique cultural, religious, and educational background. We strive to find hidden or higher meaning in patients’ symptoms, words, and actions. We assess their potential lethality toward themselves or others and examine the often tortuous course of their existence. And, unlike other physicians, we observe their transference toward us and simultaneously examine our own conscious or subconscious countertransference—channeled via thoughts, emotions, and behavior—and we scrutinize potential or real boundary violations by patients and ourselves and act judiciously. No other specialty has as wide or deep a view as psychiatry of the totality of people’s lives.
Neurobiology of wisdom
The wonder of psychiatric practice is that we somehow navigate each patient’s unique jungle of thoughts, emotions, behaviors, and cognitions and skillfully weave a biopsychosocial diagnosis and treatment plan. By doing so, we develop different regions or circuits in our brains than surgeons, radiologists, or internists do. Meeks and Jeste’s wonderful article about the neurobiology of wisdom suggests that psychiatrists’ brains probably develop “wisdom circuitry” via advanced neuroplastic connectivity in the:
- prefrontal cortex (for emotional regulation, decision-making, and value relativism)
- lateral prefrontal cortex (to facilitate calculated reason-based decision-making)
- medial prefrontal cortex (for emotional valence and prosocial attitudes and behavior).1
Is it possible that just as the finger-related motor cortex grows in pianists’ brains, psychiatrists’ prefrontal pathways undergo hypertrophy as we repeatedly assess and integrate mental observations, conceptualize a diagnosis, develop a strategic treatment plan, then counsel patient after patient on how to deal with stressors and develop more adaptive living skills and attitudes? Could those well-developed pathways enhance good judgment, decision-making, insightfulness, and wisdom?
Perhaps our medical/surgical colleagues consult with us because they have noted our ability—although by no means perfect—to assess and manage conflicting or ambiguous situations and develop wise solutions for the knotty and often painful human condition. However, they also should know that, human as we are, developing wisdom does not immunize us from making unwise decisions now and then.