By: Rebekah Daniels,
on 10/22/2015
Two women are being trained for work on a factory assembly line. As products arrive on a conveyor belt, their task is to wrap each product and place it back on the belt. Their supervisor warns them that failing to wrap even one product is a firing offense, but once they get started, the work seems easy.
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By: KatherineS,
on 4/13/2014
It is easy to delineate what clinical decision-making is not. It is not evidence-based medicine; it is not critical thinking; it is not eminence-based medicine; it is not one of many other of its many attributes; and it stands alone, with many contributions from all these fields. It is far more difficult to characterize what clinical reasoning is and very difficult to define.
But the clinicians among us deal with it every day and, I think, recognize it when we do it and observe it.
Evidence-based medicine is a mantra. But it is a difficult mantra. No one wants to say, “I reject evidence: I am a quack.” But it is complex and difficult. Evidence from the research in psychiatry comes from clinical trials, neural imaging, genetics, and other fields. Clinical trials can be read and understood. They are viewed as the sine qua non of evidence-based medicine. But the trials are conducted on patients without any other clinical conditions and are usually of very brief duration. The clinician, on the other hand, is often dealing with patients with many other syndromes and a great deal of chronicity. It is hard to make a claim, based on evidence, that the excellent clinical trial of Drug X applies to such a patient.
Neural imaging is far more difficult. It is a very complex methodology, and psychiatric studies which use it include as investigators physicists, neuroradiologists, psychiatrists, psychologists, and others. The work is so interdisciplinary that, usually, none of the authors understands the entire paper. This is a huge question, I believe, for philosophy of science. Most of these studies are conducted on a small N, with very complex statistics, and few have been replicated. What is the clinician to do with them? Many clinicians make the assumption that the spectroscopic findings somehow translate to clinical “facts”, but that is generally not a safe assumption, nor one on which to base treatment decisions as yet.
Similarly, genetics studies are also very difficult, especially because of the completely central statistical analyses which are necessary to understanding the papers — and which few clinicians have time to read or sufficient training to understand.
Many clinicians try hard to be “evidence-based”, but it is very difficult for anyone to truly sort through the evidence in order to make an on-the-spot clinical decision which will affect the health of a patient. Some journals and digests attempt to do this in order to assist clinicians, but reliance on them implies a trust in their employees which may or may not be justified.
For all these reasons, “eminence-based” reasoning has some attraction. The clinician should base his decisions on recommendations of experts rather than her or his own scrutiny of the literature. But many of the experts are quite old and have been removed from day-to-day clinical interactions for many years.
A couple of years ago I encountered a young patient with a severe, atypical depression. My immediate response was, “This patient reminds me of another patient, who had a superb response to a monoamine oxidase inhibitor, so perhaps I should try one.” This is a poor rationale for a clinical decision until it is parsed, but, in fact, the young man’s depression was categorically similar to that of the other patient, neither had responded to more traditional treatment, and there was a supportive literature for the use of a monoamine oxidase inhibitor in this type of clinical situation. The patient in fact responded well to this treatment. I believe that this type of clinical decision-making is common and that it is based on science and evidence, though sometimes the science and evidence are not immediately apparent unless the clinician thinks about it.
Clinical reasoning requires consideration of the evidence and efforts to assess it, good critical thinking, and also, in my view, the experience of interacting with and treating many patients over time. It is not a laboratory exercise but one which involves a doctor, a patient, and the world around them.
Lloyd A. Wells, Ph.D., M.D., is Consultant Emeritus at the Mayo Clinic in Rochester, Minnesota, USA. While there, he chaired the Division of Child and Adolescent Psychiatry for nineteen years and was the Department of Psychiatry’s Education Chair for twelve years. He is co-editor, with Christian Perring, of Diagnostic Dilemmas in Child and Adolescent Psychiatry.
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Image credits: (1) Wooden Sculpture of Science Genetics, by epSos.de, CC-BY-2.0 via Wikimedia Commons. (2) Sorrowing Old Man, by Vincent van Gogh, public domain via Wikimedia Commons.
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By: Rebecca,
on 5/17/2010
Edna Foa is a Professor of Clinical Psychology in Psychiatry at the University of Pennsylvania and Director of the Center for the Treatment and Study of Anxiety. Her most recent book, Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, was written with Elizabeth Hembree and Barbara Olaslov Rothbaum. The guide gives clinicians the information they need to treat clients who exhibit the symptoms of PTSD. Recently Foa was name by Time Magazine as one of the most influential people in 2010. Below she reacts to the honor.
My first reaction was that of disbelief when I learned that I had been selected for Time Magazine’s list of the 100 most influential people in 2010. I thought someone was pulling my leg. I called my husband and shared the news with him, he thought I was pulling his leg. My youngest daughter said: “get out of here, you must be joking”. But of course, we all know that the email was genuine. First, I was stunned. After all, I am not a rock star, not a head of state, not even a famous athlete. And then I was delighted. Isn’t it wonderful that someone at Time recognized the importance of the work we, clinical psychology researchers, do to help PTSD sufferers. I felt quite honored to represent our field.
As clinical scientists we know that we have a lot of powerful treatments. But we also are painfully aware of how difficult it is to make these treatments widely available. The treatments that we have for anxiety disorders are particularly efficacious and yet most clinicians do not deliver them. For many reasons it is hard to get mental health clinicians to adopt new treatments. As a result, countless individuals with anxiety and other disorders experience needless suffering that could be decreased or terminated via the application of the effective treatments we developed.
The cost of bad treatment reaches beyond individuals. Institutions and society as a whole suffer from what is a public health issue. For example, the VA, the military and insurance companies all have a stake in individuals receiving the most effective treatments for psychological disorders. And yet, there have been very few effective initiatives requiring practitioners to learn and deliver the best psychological treatments.
And so I hope that Time Magazine’s recognition of my work is in essence recognition of the tremendous importance of not only developing effective, evidence-based treatment, but more importantly, disseminating them among mental health professionals. The wars in Iraq and Afghanistan have brought home the awareness of how important it is to deliver effective treatments to the many soldiers who return from these wars with posttraumatic stress disorder (PTSD). I strongly believe that PTSD is not only a mental health disorder; it is also a societal problem. It is the responsibility of our society to help PTSD sufferers as a result of being injured at work, raped in our schools, physically assaulted in our streets, or experiencing the horror of war. We know that effective treatments for PTSD such as Prolonged Exposure (PE) can help patients regain their lives in as few as 10 sessions over the course of 5 weeks. It is no long
