Agree to Disagree: A Collaborative Perspective From a Treatment Team and Disagreeing Patient

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CLINICAL REFLECTIONS

What happens when a patient disagrees with their provider and is an expert in the field?

We present the case of “Dr Jones,” a mid-career psychiatrist with a past medical history of cerebrospinal fluid (CSF) leaks and idiopathic intracranial hypertension (IIH) who presented with altered mental status. She was admitted to the combined medicine and psychiatry unit at Grady Memorial Hospital in Atlanta, Georgia, where the hospital team’s workup suggested she had bipolar I disorder. The patient rejected the diagnosis, likely influenced by anosognosia and professional stigma.

This case explores professional identity, stigma, and the value of patient-provider case studies in psychiatric care. We provide this piece between us, the treatment team, and the disagreeing patient to share the viewpoints of different stakeholders navigating these topics in real world treatment settings. We conclude with recommendations for improving psychiatric care for mental health professionals.

The Case

Dr Jones was brought to the emergency department for altered mental status by a psychiatric advanced practice provider (APP) who was a colleague of the patient and noticed a change in behavior over the past week. Initially in the psychiatric emergency service, she was evaluated for acute mania or psychosis. At the time, history did not reveal a primary psychiatric disorder, and she was admitted to the medicine and psychiatric unit to find alternative causes of altered mental status.

When the treatment team evaluated her, she was alert and oriented to name, time, location, and event. Her answers were appropriate, and she displayed a level of insight despite some meandering in her response that was corrected with redirection. As we interviewed her, she demonstrated a desire to collaborate with us on her care, often interjecting knowledge from her medical training.

Dr Jones self-reported that she believed her change in mental status was due to issues with her pituitary, explaining that over the last 3 months she had experienced right-sided ear fullness, clear rhinorrhea, and pulsatile tinnitus. She noted 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 as well as CSF leak evaluated with a lab assay. Surgical correction had been discussed but not scheduled.

Dr Jones reported a 6-month positional headache that worsened with standing and was absent with laying, as well as increased thirst. She denied 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 had a history of alcohol use but had not consumed any in the week leading up to her admission. No other tobacco or substance use was noted.

Vitals and physical exam were unremarkable outside of an unsteady gait with normal stride and intact reflexes. Her labs were within normal range. Dr Jones was euvolemic, eunatremic, and had normal sodium urine studies. A paraneoplastic panel was ordered given her previous history of treated ductal carcinoma in situ and did not detect autoantibodies.

An MRI (Figure 1) reconfirmed the presence of a right-sided tegmen dehiscence. Consultation with ENT and neurosurgery determined that changes in mental status were unlikely to be caused by the CSF leak. A lumbar puncture was performed and revealed a slightly above normal opening pressure (25 mmHg) which was notable given the presence of an ongoing leak. The patient consented to a trial of acetazolamide 250 mg daily.

Figure 1. MRI Showing Right-Sided Tegmen Dehiscence

Collateral from both her former romantic partner and APP noted 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.

Dr Jones was offered a trial of a mood stabilizer, which she refused, believing her change in mental status was either from an underlying endocrine disturbance or posttraumatic stress disorder (PTSD). Ultimately, her mental status improved with normalization of her sleep-wake cycle. When her previous romantic partner visited, he confirmed a return to her baseline mental status (lability in mood, talkativeness, and tangentiality were still present). Dr Jones no longer met criteria for inpatient admission and was subsequently discharged. At the time of discharge, the treatment team discussed creating a collaborative case report with a desire to highlight unique dynamics around diagnosing psychiatric providers with mental health disorders. Dr Jones gave her explicit consent for this case report during routine follow-up.

Perspective of Provider Team

Dr Jones'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 had us 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 Jones. 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 Jones, 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 Jones, 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 first-hand experiences from patients and providers with medical literacy.

Patient Autonomy, Professional Identity, and Diagnostic Disagreement

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 Jones's medical expertise and right to participate in treatment decisions while also addressing what we perceived as symptoms potentially affecting her judgment. This was further complicated by Dr Jones'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 Jones’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 1 party being right at the expense of the other party being wrong, reinforcing often cited criticisms of patient-provider power imbalances.³ Alternatively, care can be more focused on finding common ground for therapeutic alliance and advancing shared treatment goals.

Stigma and Licensure Concerns

The impact on professional identity was cited by Dr Jones as a major concern in her diagnosis. Internalized stigma has been documented by health care professionals regarding mental health diagnoses.⁴ Dr Jones'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 have narrowed mandatory reporting to “only if impaired,” “only current,” and “safe-haven non-reporting” (physicians are not required to report diagnoses if they are in a physician health program).^5,6

Georgia has updated their 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.

Do you have a case to discuss? Send your composite case discussions to PTEditor@MMHGroup.com.

Mr Rab is a 4th year medical student at Emory School of Medicine.

Dr Mangal is an assistant professor at the Emory University School of Medicine. He is also a medicine and psychiatry physician.

Acknowledgement

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

References

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5. Hendin H, Reynolds C, Fox D, et al. Licensing and physician mental health: Problems and possibilities. Journal of Medical Regulation. 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. Georgia Composite Medical Board. GCMB updates mental health question on licensure applications. February 2, 2023. Accessed February 24, 2025. https://medicalboard.georgia.gov/press-releases/2023-02-02/gcmb-updates-mental-health-question-licensure-applications#:~:text=The%20question%20now%20reads%3A,%2C%20ethical%2C%20and%20professional%20manner%3F

8. American College of Emergency Physicians. Poll: workplace stigma, fear of professional consequences prevent emergency physicians from seeking mental health care. 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.