"Giovanni Fava has written perceptively about self-interested power elites within academic psychiatry…
" Bernard Carroll
Dr. Carroll’s comments are always welcomed, but his response to the last post contains a reference to an article by Dr. Giovanni Fava that puts words to a music I haven’t heard in a while. Here’s the abstract, but the full text is available online:
Background: There is increasing awareness of a crisis in psychiatric research and practice. Psychopathology and clinical judgment are often discarded as non-scientific and obsolete methods. Yet, in their everyday practice, psychiatrists use observation, description and classification, test explanatory hypotheses, and formulate clinical decisions.
Aim: The aim of this review was to examine the clinical judgment in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy.
Methods: A MEDLINE search from inception to August 2011 using the keywords "clinical judgment" and "clinimetric" in relation to psychiatric illness for articles in English language was performed. It was supplemented by a manual search of the literature. Choice of items was based on their established or potential incremental increase in clinical information compared with use of standard diagnostic criteria. The most representative examples were selected.
Results: Research on clinical judgment has disclosed several innovative assessment strategies: the use of diagnostic transfer stations instead of diagnostic endpoints using repeated assessments, subtyping versus integration of different diagnostic categories, staging, macro-analysis, extension of clinical information beyond symptomatic features. Evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment.
Conclusions: A renewed interest in clinical judgment may yield substantial advances in clinical assessment and treatment. A different clinical psychiatry is available and can be practiced now.
He introduces his paper with this:
George Engel differentiated between “scientific physicians” [clinicians who fully apply the scientific method in their care of patients and in their understanding of the disease] and “physician-scientists” [physicians whose primary commitment is to scientific research pertaining to medicine and who have little or no familiarity with the clinical process]. Clinical practice is the source of fundamental scientific challenges for scientific physicians, whereas the application of basic [including pharmaceutical] research is the preferred focus of physician-scientists. Part of the challenge and, at the same time, fascination of being a clinician lies in applying scientific methods in the care of patients and in understanding disease. Greater knowledge should result in significant benefits for the patients, and in a sense of continued development on the part of the physician. We are witnessing, however, a progressive detachment of clinicians from research, which is often accompanied by a sense of personal stagnation and tiredness. This detachment is mainly the reflection of an intellectual crisis that became more and more manifest in recent years. Psychiatrists are constantly reminded that genetics and neurosciences are going to transform and improve their practice. Biomarkers are considered the stairway to such a shift and leading journals, such as the American Journal of Psychiatry and the Archives of General Psychiatry, are pursuing this perspective. Psychiatrists may share this optimism and wait for this event. Nothing has really come in the past two decades, as exemplified by the field of psychiatric genetics, but we may be really close. Psychopathology and clinical judgment are discarded as non-scientific and obsolete methods. Yet, in their everyday practice, psychiatrists use observation, description and classification, test explanatory hypotheses, and formulate clinical decisions. In evaluating whether a patient needs admission to the hospital [or can be discharged from it], in deciding whether a patient needs treatment [and in case what type] and in planning the schedule of follow-up visits or interventions, the psychiatrist uses nothing more than the science of psychopathology and clinical judgment…
My only response is to say I wish I’d said that. I just didn’t know how. And as often is the case for old men, it reminded me of my own story. I didn’t leave a career in research in hard science because I didn’t like it. I liked it a lot. I left it because I found something I liked better – clinical medicine. And as strange as it might seem, I gravitated to psychiatry because it seemed the most scientific of the lot, more like the kind of scientific method research I really liked than practice in Internal Medicine where there’s a lot of rote. I’m not much of a rote person. In psychiatry, every case was different. Sometimes, there was a disease to treat like Schizophrenia or Manic Depressive Illness, but even then, there’s never anything routine. Most of the rest of the time, there’s a whole narrative to parse looking for the problem[s]. Then there are interventions to consider. Once made, there’s a whole new narrative to evaluate to see if the intervention had an impact, needed revising, or was wrong altogether and issued a call to start over. The only guide was the method and experience, and both were iterative. What could be more interesting or scientific than that?
And then psychiatry went off and left me. The meetings began to feel like Dr. Fava’s description, "Psychiatrists are constantly reminded that genetics and neurosciences are going to transform and improve their practice. Biomarkers are considered the stairway to such a shift and leading journals … are pursuing this perspective. Psychiatrists may share this optimism and wait for this event. Nothing has really come in the past two decades, as exemplified by the field of psychiatric genetics, but we may be really close. Psychopathology and clinical judgment are discarded as non-scientific and obsolete methods." That is how it felt. We were gathering in meetings to wait together for the future, to hear about what exciting thing might be coming down the pike, or about what had just dribbled from the mythical pipeline that offered promise. So I gravitated to other meetings, sought other counsel. Some of my friends and former students thought I had withdrawn because I was a psychoanalyst and that was the new out-group. That’s not what I thought, but I found there’s no arguing with that particular charge. I thought it was a super-science phase in psychiatry that would pass or find its right place, and I went about my business with a smaller circle of colleagues, obviously enough for me. But the semi-isolation that was good for me and my work had a price. I was unaware of the magnitude of corruption and the melding of academic psychiatry with industry. I guess you see what you want to see, and the "phase" turned out to be much more than that and kept on going. But enough of that. Dr. Fava says it all so much better than I and it’s there to read.
Friday, I was in the clinic seeing a new patient, and I felt kind of good about something I said. The patient reported being depressed and wanted to add to or change the medicine she was already taking because she was having trouble functioning. I thought she was more oppressed than depressed. She was the "executive daughter" in her biological family, managing all of her mother’s affairs long distance since a recent stroke; functioning as her sister’s marriage counselor [also long distance]; being a mother to her three kids [two of whom lived with her ex-husband because they couldn't get on with her current husband]; living with oldest son, her demanding alcoholic current husband, his ne’er-do-well addict son, and her own 38 year old brother because her mother can no longer care for him [who, by the way, thinks he's Jesus and awaits the rapture]; doing all the cleaning and cooking; working full-time as an assistant manager of a busy store with a not-very-busy manager; going to school full-time in business administration. There was more but you get the picture. What I said was that I didn’t have a pill that would make her feel good functioning in her situation, but if I did, I wouldn’t prescribe it because I’d be helping her continue to live a life that she badly needed to do something about. Fortunately, she liked what I said too, and we set about trying to figure out how she got there, and how to make some changes. I felt like a clinic·ian…