|
The Patient is Not Divided: Why Psychiatry Taught Me About Clinical Integration October 2026 | Vol. 70, No. 3 “Is this medical or psychiatric?” I heard this question posed in various ways during the course of my clinical training. Prior to my psychiatry rotation, I rarely questioned this premise. Medical training is all about categorization. Medical school teaches us cardiology, neurology, surgery, internal medicine, and psychiatry separately because only through the process of breaking down a massive amount of information is it possible to teach it. This structure is necessary. Clinical training, however, presents a very different challenge: learning how to integrate those separate disciplines in a single patient. Patients, however, do not arrive divided along the same lines. Sometimes, psychiatric history is an integral part of the differential. But sometimes, it’s the anchor. Confusion in a demented patient does not mean we skip the differential. A new complaint in a patient with schizophrenia does not mean we stop looking for a medical cause. What’s already in the chart is important but not always complete. Our psychiatric assessment should change the differential diagnosis, not replace it. While on my psychiatry rotation, I have realized that this is one of the significant changes that occur from preclinical to clinical training. The process of separating the diagnoses enables us to learn them well. However, in the clinical setting, we need to learn when these divisions do not apply to the individual being examined. When the Chart Starts Thinking for Us Medical students are trained to build differential diagnoses. It is rare for us to be taught anything about the way things work once the diagnosis has been made and starts building the differential for us. There is a term for a certain instance of this phenomenon: diagnostic overshadowing. It refers to misattributing the physical symptoms of patients to an existing mental illness in the field of mental health. Diagnostic overshadowing can stem from multiple interactions, such as health system limitations, lack of mental health literacy, stigma, and difficulty communicating.¹ It does not mean that psychiatric diagnoses do not matter at all; on the contrary. The problem comes when the diagnosis solves the problem we haven't asked yet. In the training setting, terms like "that is the patient's baseline," "there is a psychiatric history" and "this is most likely behavioral" can help in providing closure in a rather complicated case presentation. At times, they may be accurate. However, the baseline is meant to be determined, not assumed. Behavior is a form of data; it does not explain anything. The issue now becomes not only about whether the patient has a psychiatric condition but whether the condition explains the problem at hand. The Problem With “Medical or Psychiatric?” Prior to clinical rotations, "medical versus psychiatric" seemed like a helpful diagnostic dichotomy – rule out medical causes first, then look into primary psychiatric diagnoses. However, at the bedside, this hierarchy sometimes becomes blurred as there can be overlapping of the two categories and their interplay resulting in the shift in interpretation of the same symptom. It is not that the existence of such a relationship between a medical disease and the psychiatric one is not recognized by doctors. What makes the situation complicated is the psychological aspect – once this diagnosis is made, how willing are we to see the other side of it? In addition to this, our language shows such dichotomy as well – we talk about "medical clearance" before any further treatment. Different medical staff may be examining separate parts of one patient's condition. Such separation is operational at times, however, it becomes problematic if the borders created in the healthcare system start influencing the borders of our diagnostic thinking process. Studies of emergency clinicians have highlighted diagnostic problems in mentally ill patients with physical symptoms in the context of difficulty in data collection, complicated presentations, time constraints, and lack of coordination between emergency and psychiatry departments.²,³ The takeaway is not that one should mistrust psychiatric diagnoses. The takeaway is that one must not use one diagnosis to shut out the others prematurely from the differential. It might actually be a better approach sometimes to not ask: “Is this a medical case or psychiatric case?” Sometimes the question is: What medical and psychiatric variables might be contributing to my presentation? It is that small difference that makes both options possible. Psychiatry Is Not Separate From Medicine One of the most valuable things I have learned on my psychiatry rotation is that psychiatric assessment is an exercise that repeatedly calls for the clinical discipline one finds anywhere else in medicine. A shift in mental status requires evaluation of medication, substance use, vitals, labs, infection, neurologic findings, cognition, collateral history, and premorbid function. Psychiatric assessment does not supersede medical decision-making, it relies on it. And yet, in the other direction, on a medical or surgical service, issues like depression, anxiety, substance use, cognition, and behavior can affect how someone experiences his or her illness, compliance with treatment, and the viability of the discharge plans. The real issue is not who owns the patient, but rather what mixture of factors tells the true story of the patient before us. It appears to me, as I continue my clinical training, that that border is increasingly helpful in organizing medical care, but no longer very useful in describing a human being. An Osteopathic Principle Becomes Practical The first osteopathic tenet describes the person as a unit of body, mind, and spirit.⁴ In my pre-clinical years, I understood this as the philosophy of osteopathy. In my clinical years, I am beginning to understand that this is a method of thought too. It is relevant when there is already a psychiatric condition present and it is threatening to overtake any further diagnosis, when cognitive status makes it more difficult to devise a treatment, and when both biological and behavioral factors are acting simultaneously. Therefore, whole person care is not only a style of bedside manner. It can also be a protection against prematurely limiting the scope of the problem. As a student, this may be one of the hardest things to accept. From Learning in Chapters to Thinking in Patients I entered psychiatry expecting to become better at recognizing psychiatric diagnoses. However, during the rotation, I began to reconsider how I organize medical problems more broadly. The structure of medical education forces us to separate the knowledge into various categories. We are taught cardiology, neurology, surgery, psychiatry, and internal medicine individually. This structure allows us to learn medicine. At the same time, we are supposed to acquire a different skill in clinical education. We need to know whether the diagnosis we are considering applies to the patient's situation and whether there are two domains of medicine involved at the same time. However, eventually, we need to combine those chapters again. As our patients have never read them before. They present themselves with physiology, psychology, medication, circumstances, behaviors, diseases, and experiences all combined. Now, when I hear “Is this medical or psychiatric?” I still understand the usefulness of the question. I am also learning not to let it end the differential too early. Sometimes the better question is: “What else could also be true?” The patient is not divided. Our thinking should not be either. References |
Pennsylvania Osteopathic Medical Association
© Copyright 2026 Pennsylvania Osteopathic Medical Association1330 Eisenhower Boulevard | Harrisburg, PA 17111-2395
P: (717) 939-9318 | F: (717) 939-7255 | [email protected]
Privacy Policy
