Treating a physician patient with psychosis

The authors present a case of a psychotic female patient who is a former graduate of a locally prestigious medical school and has subsequently been diagnosed with schizophrenia. The patient entered treatment in an outpatient clinic following discharge from her 11th hospitalization. This hospitalization was initiated after the patient's physician friend had called the police and notified them that the patient was significantly disorganized to warrant further evaluation. Treatment was characterized by significant transference and counter-transference reactions amongst her clinicians – both treatment-promoting and treatment-interfering – based on her status as a physician. The problem of insight was a significant hurdle in the treatment of the patient as her medical knowledge of mental illness was substantially greater than her insight into her own mental illness.Throughout treatment, a number of medical-legal and ethical issues arose. Initially, the question was raised as to the legality of the actions by the patient's friend—having made a clinical assessment without having a clinical role in the patient's care. As the patient's clinical status improved and she sought to re-enter the medical field as a resident, new medical legal issues surfaced. What were the roles of the patient's treaters in maintaining confidentiality and simultaneously ensuring the safety of patients that the psychotic physician might care for?This case highlights the universality of psychiatric vulnerability. Insight in psychosis as well as the transference and counter-transference issues involved in caring for a psychotic physician are discussed. Additionally, a thorough medical-legal discussion addresses the various complexities of caring for a psychotic physician.

► The authors present the case of a physician patient with severe psychotic illness.
► The problem of insight in psychosis is reviewed including relevant treatment recommendations.
► Associated medical-legal issues regarding an impaired physician are discussed.
► The practical and ethical dilemmas of caring for a physician patient are explored.