What’s My Capacity for Getting Small?

New Mascot4There are so many things which remind me of my work that I often find it difficult to take it easy. I know we have Alice, the new mascot, but she doesn’t need me to walk her as much as Nigella did. Walking Nigella clear over to the Gift Shop did wonders for shrinking my ego.Nigella ready for her walk

I guess I’ll have to find another way to get small.

It’s getting closer to graduation for the residents. A couple of them caught me off guard with questions I didn’t quite know how to answer. One of them was about how to conduct decisional capacity assessments. It reminded me of a new article about it I saw in Psychosomatics [1]. Just when I thought nothing more could be written about the damn topic… In the conclusion section, the authors make the case for broadening the 4 abilities model to include coaching the patient in order to bring out their best decision-making capacity, letting them have their emotions in the process while not docking points for it, and making sure to identify explanatory diagnoses as well:


Physicians are practical. We have to get things done and act, often amid uncertainty. Questions of medical decision-making capacity frequently add ambiguity to clinical situations. The 4-abilities model of medical decision-making capacity does the necessary job of breaking down a highly elaborate, knotty concept into some workable components. However, that very virtue of the model can lead to its constricted application. Beyond the basics of the 4 abilities, capacity evaluations also require facilitating the patient’s best performance, appreciating noncognitive aspects of decision-making, and applying explanatory diagnoses.

Perhaps these aspects of capacity assessment are underemphasized because they are not specific to it. They are parts of good clinical care. Although the concept of capacity has a necessary legal core, the physician’s role in capacity evaluation is still a fundamentally clinical one. It therefore carries with it all of the privileges, obligations, and challenges of the rest of our work with patients in the “muddy reality of medical concerns.”

I think what also may be important to remember is that psychiatrists and internists approach decisional capacity differently, based on their perspectives. According to Tunzi and Spike [2,3]:

We believe this difference in assessing capacity is a reflection of psychiatric and adult medicine physicians’ different experiences of the health care world. Because psychiatrists frequently interact with the legal system in competency hearings, because most behavioral illness is chronic and fluctuates over time, and because the physiologic consequences of psychiatric illness are rarely irreversible (beyond acute suicidal or homicidal behavior), psychiatrists are generally reluctant to remove decision-making power from patients. While the process of psychiatric consultation often facilitates patients’ ability to understand their illness in a general way—especially regarding social consequences—asking psychiatrists to specifically evaluate medical illness decision-making capacity is often frustrating, as their frame of reference is the mental health system and the courts.

In contrast, because adult medicine physicians face acute medical problems that do not fluctuate but frequently deteriorate without treatment, they are generally reluctant to allow patients to suffer the ill effects of what they perceive to be harmful, irreversible medical decisions. While adult medicine physicians are taught to beware of paternalism, asking them to respect psychiatric patients’ self-determination is often frustrating, as their frame of reference is the intensive care unit and the morgue.

If that doesn’t overdo it for the resident who asked me the question, then there’s always my Dirty Dozen. And I still haven’t figured out how to assess my capacity for getting small.

The other question was how I approach teaching trainees. I really don’t know…and again it looks like I’m over-focused on work. The short answer to that one is I look for other role models and try to imitate them.

Where was I? How to get small, meaning not take myself too seriously. I was about to say “mindfulness practice,” but that wouldn’t fit so well– because that’s more about accepting who I am for the time being. Trying to get small would just be more doing, and not simply being in a nonjudgemental way.

As I write this, I can see outside my window to the street. Two little kids are riding by on their brand new bicycles. Dad is trotting slowly behind.

I think he’s got it–getting small, I mean. I hope it’s not too late for me.

Robin's eggs



1. Kontos, N., et al. (2015). “Capable of more: some underemphasized aspects of capacity assessment.” Psychosomatics 56(3): 217-226.
BACKGROUND: The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching. OBJECTIVE: The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded. METHODS: Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making. RESULTS: Accessing patients’ maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients’ difficulties are important components of these assessments. DISCUSSION: The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.

2. Tunzi, M., MD (2015). Assessing Patients’ Capacity to Refuse Medical Care. Let’s Talk Blog, Psychiatrist.com. 2015. Date accessed 4/30/2015.

3. Tunzi, M., MD, and J. P. Spike, PhD (2015). Assessing Capacity in Psychiatric Patients With Acute Medical Illness Who Refuse Care. Prim Care Companion CNS Disord. 16. Date accessed 4/30/2015.

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