DECISION-MAKING
How shrinks think: decision making in psychiatry Dinesh Bhugra, Yanni Malliaris and Susham Gupta
Australas Psychiatry Downloaded from informahealthcare.com by King's College London on 09/24/10 For personal use only.
Objectives: Psychiatrists use biopsychosocial models in identifying aetiological factors in assessing their patients and similar approaches in planning management. Models in decision making will be influenced by previous experience, training, age and gender, among other factors. Critical thinking and evidence base are both important components in the process of reaching clinical decisions. Expected outcome of treatment may be another factor. The way we think influences our decision making, clinical or otherwise. With patients expecting and taking larger roles in their own management, there needs to be a shift towards patient-centred care in decision making. Conclusions: Further exploration in how clinical decisions are made by psychiatrists is necessary. An understanding of the manner in which therapeutic alliances are formed between the clinician and the patient is necessary to understand decision making. Key words: decision making, psychiatry, psychiatrists.
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Yanni Malliaris Research Worker, Section of Cultural Psychiatry, Institute of Psychiatry, King’s College London, London, UK. Susham Gupta Consultant Psychiatrist, East London NHS Foundation Trust Assertive Outreach Team – City and Hackney, London, UK. Correspondence: Professor Dinesh Bhugra, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Email: Dinesh.bhugra@kcl.ac.uk
Montgomery1 asserts that phronesis (advocated by Aristotle) is practical reasoning enquiring into matters of ethics and health. As objects of knowledge, health and morals differ from physical phenomena about which one can be more certain. Scientific reason or existence is stable physical phenomena which can be known through necessary and invariant laws and need to be differentiated from practical reasoning. Montgomery also argues that doctors look for cause and its effect on patients, while patients look for effect and then the cause. This creates another level of friction between doctors and their patients. Any analysis of decision making (especially in response to medical malpractice) must include magnitude of risk and value or importance of risk. The comparison of the decisions has to be the level which other physicians
doi: 10.3109/10398562.2010.500474 © 2010 The Royal Australian and New Zealand College of Psychiatrists
Australasian Psychiatry • Vol 18, No 5 • October 2010
Dinesh Bhugra Professor of Mental Health and Cultural Diversity, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK.
octors make decisions to reach a diagnosis in a logical manner with the most obvious diagnosis being the most commonly thought one. Diagnosis enables clinicians to make management plans. Physicians draw on their diagnostic skills and clinical experience as well as scientific information and clinical research when they exercise clinical judgement.1 For psychiatry, too, the core of the doctor-patient interaction is diagnostic skills, clinical experience and information based on research. In psychiatry, unlike other fields of medicine, the emphasis on illness rather than disease makes the diagnosis and its management more complex. The subjectivity of symptoms and distress with fewer or more objective tests make psychiatry an exciting subject. Decision making in psychiatry synthesizes at least three components of biopsychosocial approaches in both diagnosis and clinical management. The diagnosis in psychiatry remains an interpretive science. Unlike many branches of medicine, psychiatry is also better in dealing with ambiguity and uncertainty. Two observations of Cassell2,3 are worth highlighting. First, knowledge by itself does not take care of sick people or relieve their suffering. Further, clinicians and medicine need a systematic and disciplined approach along with the knowledge arising from the clinician’s experience to reach diagnosis and plan management.
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