Let’s Agree to Disagree: What to Do When a Patient Disagrees

VectorBum/AdobeStock

CLINICAL REFLECTIONS

What happens when a patient who is an expert in the field disagrees with their clinician?

“Dr Smith,” a midcareer psychiatrist with a medical history of cerebrospinal fluid (CSF) leaks and idiopathic intracranial hypertension (IIH), presents to the emergency department with altered mental status. She is brought by a psychiatric advanced practice provider (APP) colleague who noticed a change in her behavior during the past week. Dr Smith is initially evaluated for acute mania or psychosis. History does not reveal a primary psychiatric disorder, and she is admitted to the combined medicine and psychiatry unit at Grady Memorial Hospital in Atlanta, Georgia, to find alternative causes of altered mental status.

When the treatment team evaluates her, she is alert and oriented to name, time, location, and event. Her answers are appropriate, and she displays a level of insight despite some meandering in her response that is corrected with redirection. She demonstrates a desire to collaborate with the treatment team on her care, often interjecting knowledge from her medical training.

Dr Smith self-reports that she believes her change in mental status is due to issues with her pituitary gland, explaining that during the past 3 months she has experienced right-sided ear fullness, clear rhinorrhea, and pulsatile tinnitus. She notes increased rhinorrhea after a stressful argument, prompting outside hospital evaluation. She met with an ear, nose, and throat doctor (ENT) who confirmed the presence of a right-sided tegmen mastoideum dehiscence and CSF leak, which was evaluated with a lab assay. Surgical correction had been discussed but not scheduled.

Dr Smith reports a 6-month positional headache that worsens with standing and is absent with lying, as well as increased thirst. She denies any nausea, vomiting, fever, aura, and neck stiffness. No clear antecedent event could be recalled in the past week precipitating the change in mental status. She also has a history of alcohol use but had not consumed any in the week leading up to her admission. No other tobacco or substance use is noted.

Vitals and physical examination are unremarkable, outside of an unsteady gait with normal stride and intact reflexes. Her labs are within normal range. Dr Smith is euvolemic and eunatremic and has normal sodium urine studies. A paraneoplastic panel is ordered, given her history of treated ductal carcinoma in situ, and does not detect autoantibodies.

FIGURE. MRI Showing Right-Sided Tegmen Mastoideum Dehiscence

An MRI (Figure) reconfirms the presence of a right-sided tegmen mastoideum dehiscence. Consultation with ENT and neurosurgery determines that changes in mental status are unlikely to be caused by the CSF leak. A lumbar puncture is performed and reveals a slightly above-normal opening pressure (25 mm Hg), which is notable given the presence of an ongoing leak. Dr Smith consents to a trial of acetazolamide 250 mg daily.

Her former romantic partner and her APP note previous, similar episodes that lasted for approximately 3 weeks, marked by periods of goal-directed activity, irritability, decreased need for sleep, and paranoid and delusional thinking, usually precipitated by stressful encounters with family or work.

The treatment team suggests she has bipolar I disorder, but Dr Smith rejects this diagnosis, likely influenced by anosognosia and professional stigma. Dr Smith is offered a trial of a mood stabilizer, which she refuses, believing her change in mental status is either from an underlying endocrine disturbance or posttraumatic stress disorder (PTSD). Ultimately, her mental status improves with normalization of her sleep-wake cycle. When her previous romantic partner visits, he confirms a return to her baseline mental status (lability in mood, talkativeness, and tangentiality are still present). Dr Smith no longer meets criteria for inpatient admission and is subsequently discharged. At the time of discharge, the treatment team discusses creating a collaborative case report with a desire to highlight unique dynamics around diagnosing psychiatric providers with mental health disorders. Dr Smith gave her explicit consent for this case report during routine follow-up.

Perspective of Provider Team

Dr Smith’s presentation highlights the diagnostic complexity when managing a patient with concurrent neurological, medical, and psychiatric conditions. Our evaluation based on conversations with colleagues in neurosurgery and ENT and the acute timing of her change in mental status led us to believe there was not a causal link between her CSF leaks and IIH with her change in mental status. Although endocrinological workup could have been pursued further, her clinical picture and labs did not support a pituitary etiology.

Collateral was a decisive factor in our workup. We had 2 independent accounts of episodes in the past with similar manic features. Additionally, confirmation from her previous romantic partner of baseline hypomanic features added credence to the possibility of undiagnosed bipolar I.

We believe the mania diagnosis label carried significant weight with Dr Smith. Her concern about trialing a mood stabilizer and subsequent frustration at the provider team suggested an underlying worry about the long-term repercussions of being a provider with a mental health diagnosis. Rather than focus on diagnostic certainty, we formed a collaborative relationship with the patient that helped improve her overall mental status while respecting her autonomy.

Our clinical assessment indicated no current impairment in her ability to practice medicine safely. When we discussed state medical board reporting requirements with Dr Smith, we determined this situation did not meet mandatory reporting criteria. We provided resources about voluntary reporting guidelines so she could make an informed decision about any disclosures to state medical boards.

Perspective of Disagreeing Patient

The following is a direct account from the patient, Dr Smith, with minimal changes added around formatting and syntax:

My recollection of the hospitalization is fragmented, like a dream. The symptoms I experienced included confusion about time, agitation, extreme inattentiveness, difficulty following directions, perseverative speech, a dyssynchronous sleep-wake pattern, aphasia, and impaired balance. I firmly believed these symptoms stemmed from my underlying medical conditions rather than a psychiatric disorder.

The diagnosis of bipolar I disorder came as a shock…. My professional identity significantly influenced my response to the diagnosis. I feared potential career repercussions and [was skeptical of] the medical team’s insistence on psychiatric medication. I was not hallucinating or overtly manic, and I believed my condition was a form of delirium that would improve with basic medical interventions like orientation, hydration, and rest.

Critically, I have never accepted the bipolar diagnosis. [Although] I remain open to mental health labels secondary to my medical condition, I see no evidence supporting a primary bipolar diagnosis. My previous mental health experiences were limited to grief-related issues, major depressive disorder, premenstrual dysphoric disorder, ADHD, and [PTSD].

Despite the challenging experience, the hospitalization motivated personal growth. I reconnected with meaningful activities and began therapy to address unresolved issues related to cancer, grief, and stress. My message to the psychiatric community is clear: approach [medically trained] patients as medical doctors first, remembering that our specialty embraces uncertainty—a principle particularly relevant when investigating complex medical conditions.

Discussion

We present this case to promote a novel form of psychiatric literature, one that embraces narratives from medically trained patients and providers. Although traditional academic literature discusses concepts like professional stigma and diagnostic heterogeneity in abstract terms,^1,2 we hope these case reports provide invaluable firsthand experiences from patients and providers with medical literacy.

Patient Autonomy

Although respect for patient autonomy is a cornerstone of medical ethics, psychiatric care presents unique challenges when a patient’s decision-making capacity may be affected or where anosognosia may be present. The treatment team faced several ethical tensions: respecting Dr Smith’s medical expertise and right to participate in treatment decisions while addressing what we perceived as symptoms potentially affecting her judgment. This was further complicated by Dr Smith’s valid concerns about professional implications and her well-reasoned medical alternatives to her symptoms.

Although this patient-provider interaction could have been dominated by who had the “right” diagnosis, we intentionally chose to focus on what would improve Dr Smith’s mental status. Even though she rejected the bipolar diagnosis, she engaged actively in the medical workup and participated in discussions about her care. This suggests that maintaining autonomy does not necessarily require complete diagnostic agreement. Rigidity around diagnostic agreement may reinforce a traditional hierarchy of one party being right at the expense of the other being wrong, reinforcing often cited criticisms of patient-provider power imbalances.³ Alternatively, care can focus more on finding common ground for therapeutic alliance and advancing shared treatment goals.

Stigma and Licensure Concerns

Dr Smith cited the impact on professional identity as a major concern in her diagnosis. Internalized stigma has been documented by health care professionals regarding mental health diagnoses.⁴ Dr Smith’s fears about career implications and professional reputation speak to a broader set of dilemmas of providing psychiatric diagnoses to providers.

Chief among those are perceptions around mandatory reporting to state licensure boards. Although state medical boards previously required reporting mental health diagnoses, a set of reforms heterogeneously adopted by state boards has narrowed mandatory reporting to “only if impaired,” “only current,” and “safe- haven nonreporting” (physicians are not required to report diagnoses if they are in a physician health program).^5,6

Georgia has updated its requirements in 2023 to “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner?” as well as safe haven provisions.⁷

This patchwork adoption by states has not produced a meaningful shift in pursuing psychiatric care. A recent sample of frontline emergency medicine providers found that 45% of them would not seek mental health support due to concerns around professional retribution.⁸ Exacerbating this concern is the elevated prevalence of occupational stigma among mental health care providers toward psychiatric diagnoses.⁹ Reasons for this are varied but include societal perceptions of what it means to have a mental illness, stereotypes or judgmental language used by colleagues when working with psychiatric patients, and the belief that carrying a mental health diagnosis makes one unfit to practice.¹⁰

Future Implications

Looking ahead, we believe several approaches could improve care for mental health care professionals seeking psychiatric care. First, alignment across state licensure boards around reporting requirements would create consistency and reduce confusion around duty to report. Augmenting those efforts with provider education can help bridge the gap between perceived and actual reporting obligations. Lastly, special pathways should be considered for health care providers seeking mental health care. It is abundantly clear that providers are hesitant about seeking psychiatric support.⁴ Designing specialized programs for health care providers with enhanced privacy protections and confidential peer support networks for psychiatric illness could increase treatment seeking and mitigate professional stigma.

More fundamentally, the medical community must consider a cultural shift toward mental health care. Current approaches are conservative relative to the mental health burden in provider communities.¹¹ A more direct path would promote open dialogue about mental health challenges and support from employment networks, state licensing boards, and medical leadership on this topic.

These steps, combined with continued efforts to reduce stigma and improve support systems, could help create an environment where health care providers feel safer seeking mental health care. The goal should be to move toward a health care system that supports provider well-being while maintaining appropriate safety measures for both providers and their patients.

Dr Rab is a psychiatry resident at Emory University School of Medicine in Atlanta, Georgia. Dr Mangal is an assistant professor at the Emory University School of Medicine. He is also a medicine and psychiatry physician.

Acknowledgment: We want to thank “Dr Smith” for granting permission to share her story, her willingness to collaborate, share her account, and partner with us on this piece.

References

1. Allsopp K, Read J, Corcoran R, Kinderman P. Heterogeneity in psychiatric diagnostic classification. Psychiatry Res. 2019;279:15-22.

2. McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22 suppl 2(suppl 2):ii33-ii39.

3. Nimmon L, Stenfors-Hayes T. The “handling” of power in the physician-patient encounter: perceptions from experienced physicians. BMC Med Educ. 2016;16:114.

4. Brower KJ. Professional stigma of mental health issues: physicians are both the cause and solution. Acad Med. 2021;96(5):635-640.

5. Hendin H, Reynolds C, Fox D, et al. Licensing and physician mental health: problems and possibilities. J Med Regul. 2007;93(2):6-11.

6. Saddawi-Konefka D, Brown A, Eisenhart I, et al. Consistency between state medical license applications and recommendations regarding physician mental health. JAMA. 2021;325(19):2017-2018.

7. GCMB updates mental health question on licensure applications. News release. Georgia Composite Medical Board. February 2, 2023. Accessed February 24, 2025. https://medicalboard.georgia.gov/press-releases/2023-02-02/gcmb-updates-mental-health-question-licensure-applications

8. Poll: workplace stigma, fear of professional consequences prevent emergency physicians from seeking mental health care. American College of Emergency Physicians. October 26, 2024. Accessed February 24, 2025. https://www.emergencyphysicians.org/article/mental-health/poll-workplace-stigma-fear-of-professional-consequences-prevent-emergency-physicians-from-seeking-mental-health-care

9. Shi XL, Li LY, Fan ZG. Psychiatrists’ occupational stigma conceptualization, measurement, and intervention: a literature review. World J Psychiatry. 2023;13(6):298-318.

10. Gupta S, Kumar A, Kathiresan P, et al. Mental health stigma and its relationship with mental health professionals - a narrative review and practice implications. Indian J Psychiatry. 2024;66(4):336-346.

11. Harvey SB, Epstein RM, Glozier N, et al. Mental illness and suicide among physicians. Lancet. 2021;398(10303):920-930.