Commentary: On Doctors and Lawyers

As a young forensic psychiatrist learning to develop relationships with attorneys, I could have hoped for no better role models than Howard Zonana and Stephen Wizner. From my first days at Yale, it was clear that these two men enjoyed not just a collegial relationship, but a true friendship that has grown from almost four decades of collaboration, mutual respect, and a shared vision of what is possible when physicians and attorneys work together. I consider myself extremely fortunate to have been able to learn from their example.

In the spirit of engaging in a frank discussion, however, I want to acknowledge that Professor Wizner painted a somewhat rosy picture of the relationship between doctors and lawyers in his article, “Learning to Collaborate: The Teaching Legacy of Howard Zonana in Forensic Psychiatry.”¹ Professor Wizner describes three instances in which he and Dr. Zonana were able to set aside egos, navigate massive bureaucracies, and eventually effect real change in the lives of psychiatric patients. While I do not doubt the veracity of these accounts, I did find myself wondering whether such successful collaborations would have been possible with any two other individuals, as the unequivocally positive outcomes that Professor Wizner describes can be, at least in my experience, difficult to achieve. More often than not, lawyers and doctors butt heads.

Like many former Yale forensic psychiatry fellows, I recall my experiences at the Yale Law School as among the most difficult and dreaded of my training. When cases were being assigned by Dr. Zonana, my colleagues and I silently prayed, “Please, don't let me be assigned another asylum or prison case!” Our dislike for the law school cases was complex and went beyond the logistical challenges of driving long distances to prisons in other states, fielding phone calls from anxious law students at all hours of the night, and conducting interviews through multiple interpreters. Those things were certainly difficult, but there was also something more viscerally uncomfortable about the law school cases. When conflicts arose with the student attorneys, I found myself unable to use the typical forensic psychiatrist's defense of smugly dismissing the attorney's opposing viewpoint as a function of his or her underhandedness/aggression/incompetence (fill in pejorative descriptor here). After all, these were Yale law students—the best and brightest young legal minds. In their presence, there was no choice but to face the reality that was rapidly coming into focus: that lawyers and doctors are fundamentally different creatures.

One of my first trips to the law school as a forensic fellow demonstrated this point perfectly. My task on that day was to sit in on law students' interviews of clients in the Prison Legal Services clinic and give them feedback about their interviewing technique. The first student I observed was fantastic, but the second one barely engaged with the client on a human level and was instead focused on getting through a list of prepared questions that he had written down. Afterward, I gave him some fairly innocuous feedback about making eye contact and pausing to listen, and I was truly taken aback when he responded by saying, “No, I think you're wrong. I'm a lawyer, and you're a psychiatrist, and so we have different styles because we have different goals.” With just two sentences, he summarily rejected not only my critique of his interviewing style, but even the legitimacy of my being in the room in the first place. I went home that day thinking, “Well, that would never happen on a surgical rotation.”

Three years later, I still marvel at how differently medical students and law students approach problem solving. Medical students tend to accept facts at face value, love to memorize, and slavishly follow the established hierarchy. Law students, in contrast, talk back, find loopholes, and challenge authority with ease and confidence. It has taken me a long time—and I'm not sure I could have done it without Dr. Zonana's example—not to recoil from the attorneys' aggressive approach and to acknowledge that there is something to be learned and gained from it. Slowly but surely, I have been getting in touch with my inner lawyer.

The most important turning point in that journey came about a year ago, when I began working in a prison. Before I started the job, I knew that patient care was still far from optimal in correctional settings, but I thought that I was prepared for the challenges of trying to provide mental health care within a system that allotted just one psychiatrist to care for a facility of 900 inmates. In many ways, thanks to the excellent training I received in my residency and fellowship, I was prepared. Whether in a prison or a community mental health center, psychosis was still psychosis, and depression was still depression. However, what I did not anticipate was how strongly I would react to the experience of seeing my colleagues providing substandard medical care simply because the patients were inmates—that is, second-class citizens—or because the staff themselves felt overburdened and afraid. I quickly realized that the psychiatrist's traditional stance of passively listening and focusing on internal conflicts was not going to be very effective in that environment. Perhaps it should have been obvious all long, but for me it took the experience of working in a setting where my fundamental values as a physician were routinely offended to realize that good doctors need to stand up for what is right. As physicians, we owe it to ourselves and to our patients to incorporate some of the lawyers' spirit into our professional identities and to fight for what we hold dear. Let us not make the mistake of allowing attorneys to corner the market on passionate advocacy.

In my day-to-day routine as a prison psychiatrist, I am grateful to Dr. Zonana for helping me to remember that inadequate medical care was never intended to be part of the punishment of incarceration. In my moments of quiet reflection, I am grateful to him for teaching me that idealism in medicine is not the sole province of the young. But most of all, I am grateful to him for showing me that, regardless of whether you are a doctor or a lawyer, there is a time for listening, and there is a time for action. In my opinion, Howard Zonana's true greatness is that, for 40 years now, he has had the wisdom to know the difference.

• American Academy of Psychiatry and the Law