Judging a Book By Its Cover


It is tempting to use our sense of sight to make snap judgments about people, places and things.

Think about it. When you walk into a restaurant, if you see a sparkling clean dining room, you probably assume that the kitchen looks the same and that the food will be prepared in a clean, safe environment. When you see a well-dressed pilot and crew walking onto an airplane that has been cleaned, fueled and prepped for flight, you assume that you are going to safely make it to your next destination. 

The same thing happens when we meet people for the first time. It takes only a second, a small fraction of a second actually, to make a snap judgment about a person, whether you trust them or not, and whether you like them or not. 

In the emergency room, I see all sorts of people for psychiatric consultations. I see little kids who are there with their parents, self-proclaimed drug addicts who are there to score their next fix, and elderly men who have lost their spouses and are contemplating suicide. Some of them have not bathed in weeks. Some of them wear tastefully applied makeup and have expensive haircuts. Some of them smile at me with straight, gleaming white teeth, while others have two teeth left in their head if that. Some people sit as far away from the camera as possible, face fixed in skepticism and arms tightly folded across chest in the universal “don’t bother me” sign. Others sit so close to the screen that I have a hard time seeing them at such an acute camera angle.

Before the camera comes on and my next patient is seated in front of me ready for the interview, I have had a chance to review the consultation request, vital signs, nursing notes, the doctor’s physical examination, lab reports, EKG printouts, CT scan interpretations, and a few data bases of medical information. I have a pretty good idea which direction my inquiry will take, what details I still need, and what disease processes I’m going to be looking for before I ever physically see the patient. 

When the call comes in and I see the patient for the first time, the visual cues are very important. Someone who has a flat, expressionless face may be depressed, have Parkinson’s Disease, or have had a stroke. Someone who is in constant motion, fidgeting and not able to keep still may be in active alcohol withdrawal, have akathisia from antipsychotic medications, or simply be anxious about being in the emergency room. Someone who scans the room, fearful and paranoid, may have a primary psychotic illness like schizophrenia, or they may have snorted bath salts and be high as a kite. 

In spite of my training in psychiatry and many years of clinical experience across a broad variety of settings, I do the same thing you would do when I see someone on camera for the first time. I make a snap judgment, not even a conscious one at times, about the person I see. It’s human nature. 

The difference is, I have been trained to put that aside and to evaluate that person based on information given to me by the requesting emergency department, results of tests and studies that have been done or will be ordered, the clinical interview and mental status examination of the patient, and the synthesis of all that data to come up with a good, solid, working diagnosis that will then drive my recommendations to the requesting doctor. 

That can make all the difference in the world. A blinking, staring, uncooperative “psychiatric” patient may be in untreated status epilepticus. A severely “anxious” patient who has been confined to a hospital bed for days may be getting ready to have a massive pulmonary embolism that will kill them. A wildly agitated, threatening, hostile patient that frightens the ED staff may be in fact so paranoid that he feels he must “kill or be killed”. 

In the evaluation of mental health patients, as in life in general, you can’t always judge a book by its cover.


The picture above is of my signed copy of The Three Faces of Eve by Corbett H. Thigpen and Hervey M. Cleckley. It sits on the shelf next to my grandmother Ursula Hall’s Shakespeare Complete Works from 1927. 


8 thoughts on “Judging a Book By Its Cover

  1. I wonder how often your initial gut instinct is actually right…I would suspect it’s most of the time. I think it’s likely you subconsciously pick up all the little not quite right bits that don’t fit the obvious…it’s the space where the art and science of medicine meet.


  2. Jocelyn

    I agree.

    I think that with time and experience, the sixth sense or gut check becomes more and more reliable.

    I don’t make decisions based solely on that, but if I’m getting ready to do something that makes me cringe or think twice, I pay attention to it.



  3. Oh, for many reasons, actually. 🙂
    First, because it shows, once again, how much you care about people (whom you not just see as “cases”).
    Then, because this is something I’ve tried to apply for many, many years. You know, when I was young and pretty, I was small and thin,delicate in shape, had looooooong blond hair, and lived in a particularly machist area. Guess how difficult it was for me to be taken seriously, professionally speaking… I learned my lesson well. OK, I used all this to my advantage, like many women in this background, but well, I’d prefered to be judged for what I was and did, not only for what I looked like.
    And now that I’m no longer young, slim and pretty, it’s become even worse for me. 😀
    So I have learned, a long time ago, not to judge people only from the first sight and make my own opinion (that, as Jocelyn pointed, was sometimes exactly what I would have thought, had I followed the first sight a priori…). 😉


  4. I have another reason.
    A decade ago, I translated A. Maslow’s “The Farther Reaches of Human Nature” in which I found particularly interesting his views about what he had called “holistic medicine”, i.e., taking the person as a whole to treat him, even his (invisible in regards to the symptoms) background, way of life, all the events occured during this very day, etc.
    I also liked his views regarding being a perfect neutral therapist, one who doesn’t lead the patient’s words or thoughts.
    Excuse me, my English is no longer fluent enough for me to explain this as clearly as I would.


  5. This is a great article. I think this topic encompasses self-stigma, as well. In my case, I felt that if I looked good, it meant I was normal. Looking good caused all sorts of problems, though, because my mental health issues weren’t being addressed. I became very sick person trying very hard to look like a normal person. When I focused on being a well person, my life improved.


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