During a recent weekly academic session, the theme was organic psychiatry. During the expert-led discussion, an old age consultant psychiatrist shared a case that stayed with me.
The patient had presented with symptoms of depression. There was low mood, loss of interest, reduced energy, and all the features that would lead most clinicians to consider a depressive illness.
Treatment was started. Reviews were conducted. Yet something did not fit. The symptoms continued to progress despite intervention.
Further investigations eventually revealed the true diagnosis. The patient had pancreatic cancer.
As psychiatrists, we are trained to listen carefully to stories. We spend years learning to identify patterns in thought, emotion, behaviour, and relationships.
We learn to recognise depression, psychosis, anxiety, trauma, grief, and personality difficulties. Over time, pattern recognition becomes second nature.
Yet one of the greatest dangers in medicine is that pattern recognition can quietly and insidiously turn into assumption.
The case immediately reminded me of a colleague during my time practicing in Malaysia. She was allocated a young patient who appeared to be suffering from treatment-resistant depression.
Many clinicians might have responded by adjusting medication, revisiting psychological formulations, or considering alternative psychiatric diagnoses.
Instead, she became concerned that something was being missed.
We know that conditions such as hypothyroidism, folate deficiency, and Vitamin D deficiency can all present with depressive symptoms, and routine blood tests are often part of the assessment process. Yet she felt there was something more.
She repeated the blood tests and performed a thorough physical examination. She found a lump.
When the results returned, the blood tests did not look right either. Something about the overall picture refused to fit neatly into a psychiatric explanation.
She referred the patient for further medical assessment. The eventual diagnosis was lymphoma.
Neither story is really about cancer. They are stories about humility.
One of the most important lessons I have learned in psychiatry is that not every patient who reaches our clinic has a psychiatric illness.
Sometimes, they do. Sometimes, they have depression, schizophrenia, or bipolar disorder. And sometimes, they have a medical condition that has borrowed the language of psychiatry.
A patient with hypothyroidism may present with symptoms indistinguishable from depression. A frontal lobe tumour can manifest as personality change.
Autoimmune encephalitis may first present with psychosis. Vitamin deficiencies, neurological disorders, endocrine abnormalities, sleep disorders, infections, malignancies, and medication side effects can all masquerade as psychiatric illness.
The mind and body have never respected the artificial boundaries created by medical specialties.
Patients certainly do not arrive announcing which department they belong to. They simply arrive in pain or in some form of dysfunction.
I suspect that many doctors can remember a patient who taught them this lesson. I certainly can.
Throughout my psychiatric training, there have been moments when the diagnosis initially seemed obvious. The symptoms appeared to fit well into familiar psychiatric frameworks.
Yet something about the patient’s presentation created a sense of unease. Perhaps the timeline did not fit. Perhaps the severity of symptoms felt disproportionate. Perhaps the patient was not responding in the way one would reasonably expect.
These moments are uncomfortable because they force us to confront uncertainty.
In medicine, an often-touted aphorism is that when we hear hoofbeats, we should think horses rather than zebras. Most of the time, that advice serves patients well.
Common things are common, and pattern recognition remains one of the most valuable diagnostic tools we possess. The difficulty arises when the patient in front of us happens to be a zebra.
Medicine often celebrates diagnostic brilliance. We admire clinicians who arrive quickly at the correct answer. We enjoy stories where an obscure diagnosis is identified through a flash of insight.
In reality, good medicine frequently looks much less dramatic. Often, it consists of a clinician quietly saying, “I might be wrong.” Those four words are among the most important in healthcare.
They create space for curiosity. They allow us to revisit our assumptions, ask another question, perform another examination, or order another investigation. Most importantly, they protect patients from the consequences of our certainty.
As psychiatrists, we may be particularly vulnerable to diagnostic anchoring. Once a patient has been referred to mental health services, every symptom risks being interpreted through a psychiatric lens.
Weight loss becomes depression. Poor concentration becomes anxiety.
Interestingly, once a patient has an established mental health illness, their subsequent ailments are often shoehorned into a psychiatric relapse of one form or another by other medical practitioners as well.
Sometimes, those explanations are entirely correct. Sometimes, they are not. The challenge lies in knowing the difference.
I have also always found it intriguing that psychiatry is often criticised for being “less medical” than other specialties. Yet in many ways, psychiatry constantly demands broad medical thinking.
A psychiatrist must consider neurology, endocrinology, pharmacology, infectious diseases, genetics, developmental disorders, and the social circumstances surrounding a patient’s life.
The task is not simply to identify psychiatric symptoms. Sometimes, the task is to determine why those symptoms exist. That distinction matters.
A diagnosis should never be the end of curiosity. It should be the beginning of it.
The patient with pancreatic cancer and my former colleague’s patient with lymphoma both benefited from clinicians who refused to stop asking questions.
They recognised that treatment resistance was itself information and were willing to abandon their initial assumptions when the evidence demanded it.
There is a tendency in medicine to equate confidence with competence. Yet some of the finest clinicians I have encountered possess a different quality. They remain curious and cautious. They remain open to being wrong.
Perhaps that is what experience truly teaches us. Not certainty, but humility. Not the belief that we always know the answer. But the wisdom to recognise when we do not.
Because sometimes depression is depression. And sometimes it is pancreatic cancer. Sometimes it is lymphoma.
And occasionally, the most important diagnostic skill a doctor can possess is the courage to realise that the patient in front of them may not belong to their specialty at all.
The author is a psychiatrist.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
