Sunday, March 27, 2011

Expert Opinion in Psychiatry

I think it might be time for us to reevaluate who the "experts" in psychiatry are (and this might apply to many more fields as well). Typically, as the story goes, "experts" in any field are the academics, those who spend time doing research, reviewing research, administrating departments, and teaching medical students and residents. It is not an understatement that provision of clinical care is often not the primary focus of people in academic positions, especially when a bulk of their salaries come from research or their other additional endeavors. This is especially the case when so-called "thought leaders" or "experts" in psychiatry spend a good deal of time at conferences that can last up to a week. Many of these folks attend multiple such conferences a year. So how is it, then, that they can claim to be "expert" in a field with which they have diminishing clinical contact? And when --and this is a big and-- the quality of psychiatric research is so poor and the data on psychiatric medication (as a whole) is miserable, how is it that these "thought leaders" can claim to be expert in anything but the status and results of meager research? ...And I won't even go into the trickery that study authors use to tease-out significant results from largely failed studies.

Some academics argue for a pragmatic approach to psychiatric diagnosis and treatment; most notably these include the architects of the recent DSMs. It seems to me (and in my lowly clinician opinion) that a pragmatic approach would involve interrogating the experience of actual practicing clinicians, those at the front-lines of psychiatry. I guarantee that the average psychiatrist is seeing hundreds, if not thousands, more patients than your run-of-the-mill "expert" or "thought leader," each year.

I am arguing here for an elevation of the importance and relevance of practicing non-academic psychiatrists and their cumulative experience, and an allowance that extensive clinical experience that leads to above-average outcomes (which is a big deal in psychiatry) would allow one to be called an expert.