Medicine is a field of the unknown. This is especially true of psychiatry and often intriguing to new physicians or researchers: the possibility of discovery.
As residents, we are taught to choose antidepressants for patients based on 1 or 2 key studies, and more often than not, we simply choose based on adverse effects. We sit with therapy patients as we concurrently learn therapy, trying techniques or occasional interpretations, knowing full well that if we are wrong, a patient will tell us, and we can repair ruptures in the therapeutic relationship.
Most of the time, if we flip a coin to make a decision and we make a wrong or ineffective choice, we can just try heads instead of tails the next time. What is the worst that can happen? Except, of course, when it comes to our most frequent coin flip—whether the patient poses a danger to himself or to others.
He was a well-dressed young man in his early 20s. He was relaxed calmly on the gurney in the emergency department awaiting my arrival. His wife sat next to him, holding his hand. He had no psychiatric history, no hospitalizations, and no suicide attempts. He denied all psychiatric symptoms, except occasionally feeling depressed and having some trouble sleeping. He had never been violent, and despite my asking multiple times in different ways, he had no plans, thoughts, or intent to harm anyone. He did not own or have access to a gun. In fact, he had never used one.
As I looked at the young man in front of me, the words of the ED physician echoed in my head: “He said to the nurse at his primary care doctor’s office that he was having thoughts of shooting other people. They documented it in an outpatient note, and then they told him to come and get psychiatrically evaluated. I think they wanted him to be put on a legal hold.”
Maybe the patient is lying to me, I thought. He doesn’t look homicidal, but what does that even look like? Maybe I should decide based on their worries. I mean, they were concerned enough to send him to the hospital.
I then decided to ask him directly about the call to his primary care doctor. He said that he maybe had a thought or two about shooting other people, and was worried, so he called his doctor. He said he wasn’t thinking that way anymore. He reiterated that he was never serious about the thoughts and did not have access to a weapon. He said emphatically, “I would never try to kill anyone, Doc; it sounds crazy just saying it. That’s why I told the doctors in the first place, and that is why I came here.”
Dr. Gold is a PGY-3 Resident, Department of Psychiatry, Stanford University, CA. She reports no conflicts of interest concerning the subject matter of this article.