Decisional Capacity: Rethinking the Standard of Care with Dr. Omar Mirza

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen continues his conversation with Dr. Jacob Appel, covering two intersecting frontiers. The replacement of human physicians by AI "replicants" and the emerging use of AI as a surrogate decision-maker, or "robo-proxy," for patients who lack decisional capacity. Dr. Appel argues that while AI will outperform human physicians in probabilistic, pattern-recognition tasks, it is structurally incapable of providing the authentic empathy, shared vulnerability, common sense, and irrational human trust that constitute the actual substance of healing and that deploying replicant physicians at scale will produce a deeply inequitable two-tiered healthcare system where wealthy patients see humans and less wealthy patients see machines.

In this episode of Psychiatry Bootcamp, Dr. Mark Mullen welcomes Dr. Jacob Appel, psychiatrist, attorney, bioethicist, polymath, and emergency psychiatrist, for a rigorous and clinically grounded critique of the Applebaum-Grisso "Four Abilities Model" of decisional capacity assessment. Dr. Appel traces the model's origins in the 1980s as a patient-empowerment tool, examines how its statutory adoption across more than half of US states has calcified it beyond its original intent, and describes in detail the categories of patients for whom the model systematically fails.

In this episode of Psychiatry Boot Camp recorded live at Saint Louis University, Dr. Mark Mullen is joined by Dr. Kristin Mueller, an emergency medicine physician and physician-researcher at Washington University in St. Louis, for a discussion on firearm violence as a public health crisis. Dr. Mueller, who works closely with the Life Outside of Violence hospital-based violence intervention program, walks through the clinical fundamentals of lethal means counseling, including a live mock counseling session demonstrating how to approach a patient in mental health crisis with access to firearms. The conversation covers practical, evidence-informed strategies for secure storage counseling, verbal de-escalation, and navigating patient resistance without leading with statistics alone.

Dr. Mark Mullen welcomes Dr. Allison Hadley, a psychiatrist and medical director of the psychiatric emergency service at Oregon Health & Science University, for a discussion on motivational interviewing in high-acuity psychiatric settings. Dr. Hadley introduces a novel teaching framework that draws on Tina Fey's rules of improv from her memoir Bossy Pants, mapping core improv principles, including "yes, and," making statements rather than only asking questions, and treating perceived mistakes as opportunities, onto the foundational techniques of motivational interviewing. The conversation covers the OARS mnemonic (open-ended questions, affirmations, reflections, and summaries), the relationship between motivational interviewing and trauma-informed care, and practical strategies for identifying and reinforcing patient change talk.

Dr. Mark Mullen welcomes Dr. Christine Crawford, Chief Medical Officer at the National Alliance on Mental Illness (NAMI) and author of You Are Not Alone: For Parents and Caregivers, alongside Steve Hoffmann, Senior Vice President and Chief Preclinical Officer at the Foundation for the National Institutes of Health (FNIH). Dr. Crawford discusses NAMI's mission and its 650 chapters nationwide, the concept of the "distress radius" as a framework for identifying when a child's behavioral changes warrant professional evaluation, and practical strategies for engaging skeptical patients and families through primary care. She also highlights dialectical behavioral therapy (DBT) as a broadly applicable clinical tool and underscores the importance of evidence-based education for patients and caregivers navigating the mental health system. The conversation then shifts to Steve Hoffmann's work at the FNIH, including the newly launching Multimodal Assessment and Phenotyping in Depression (MAPD) study, a longitudinal, multi-site initiative designed to identify biological, clinical, and digital biomarkers associated with depression subtypes. Hoffmann outlines the study's design, including neuroimaging, genetic testing, digital wearables, and patient-reported outcomes, with the goal of moving depression treatment away from a trial-and-error model toward a precision medicine approach. Dr. Crawford and Hoffmann both emphasize the importance of including patient voices in research design, drawing parallels to the foundational impact of the Alzheimer's Disease Neuroimaging Initiative (ADNI) on that field.