long overdue…

Posted on Friday 27 June 2014

by Paul Summergrad, M.D.
June 27, 2014

I recently covered on our inpatient psychiatry service at Tufts Medical Center. It is always valuable to see patients at the bedside and to spend time with wonderful psychiatric residents. As usual, the level of both medical psychiatric comorbidity and clinical complexity was challenging, as were the efforts to find the right clinical care and navigate a mental health system that is often fragmented and difficult at best. It was nevertheless greatly rewarding to see patients, to learn something about their life stories, and try to select care that was based on the best available science, and, when none was available, upon clinical experience and judgment…
To have an APA President acknowledge that the mental health system is "often fragmented and difficult at best;" to talk about learning "something about [patient’s] life stories;" and including "clinical experience and judgment" in the same sentence as "the best available science;" all feel like a cool breeze on a hot summer day after listening to years of dreams for some near-term biomedical future that never quite seems to materialize.
By this I meant that we must always remember, first and foremost, that we are physicians. It is thus incumbent upon us to be aware of the best scientific evidence available when we make clinical decisions, doing so in the context of the total needs — medical and otherwise — of our patients. It means to speak on their behalf even when it may bring us into conflict with others whose primary focus may be financial, legal, or ideological. It requires us to be deeply knowledgeable not only about the scientific literature and best practices, but also to have more than a passing familiarity with the limitations of that literature and to be prepared to speak when we must despite those limitations. And to do so on our patients’ behalf, not our own…
He adds speaking on behalf of our patients "even when it may bring us into conflict with others whose primary focus may be financial, legal, or ideological" and having "more than a passing familiarity with the limitations of [our] literature." Here he addresses the restraint on therapeutic zeal embodied in the ethical injunction, "first, do no harm" – too long neglected by organized psychiatry. And by mentioning the "financial, legal, or ideological" forces, he names those things that we all know have contaminated not only organized and academic psychiatry, but also many practitioners.
Even more importantly, we must always be mindful that as physicians we have a special responsibility to speak from our rich clinical experience, and most importantly, from the best science available, wherever that may take us and regardless of opposition. These values and clinical and scientific expertise must be the primary touchstones of our policies and public statements about psychiatry. People may not always like what we have to say, and they may often disagree with it. But if we speak as physicians from our best understanding of what the science of our field is, and our honest view of the best interests of our patients, then they do listen. Ultimately, they will often trust, respect, and rely on our opinion…
Obviously, the things Dr. Summergrad is saying in this piece are just what I’d want to hear, particularly when said from his position as president of the APA. But even more important, the intended audience are the psychiatrists he’s been elected to lead. The themes that touch on medical ethics, humility in the face of the limits of our knowledge, and the balance between science and clinical experience have been too long absent from  the rhetoric of the APA, and his repeated reminders that we must speak on our "patients’ behalf, not our own" is long overdue. High marks from this old man…
    June 29, 2014 | 2:59 PM

    Rhetoric is rhetoric as far as I am concerned. The key question is whether or not he actually does anything. There are several critical issues that can be acted on to improve both the practice environment and enhance patient care that the APA can address at a policy level. The usual excuse that I have heard over the past 30 years has been the political structure of the APA nullifying the power of the President and the big tent philosophy of the APA not wanting to lose members that might support an interest affected by political action. It does seem to take an activist President supported by activists within the political structure to get anything done.

    June 29, 2014 | 7:51 PM


    The key question is whether or not he actually does anything.

    Of course that’s right, though he gets some credit for even knowing the right things to say – an improvement over recent predecessors. It’s hard for me to imagine that the general membership wouldn’t welcome changes.

    June 30, 2014 | 2:03 PM

    dr mickey,

    don’t you find his semi-endorsement of the DSM-IV towards the end a little frightening?

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