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Who should make psychiatric diagnoses?


Psychiatry was in the vanguard of developing the multi-disciplinary team practice that is now the norm in modern medicine. The need to draw widely from other disciplines to plan care was brought home to us as we started moving patients out of asylums in the 1960s. In the UK this drew heavily on Therapeutic Communities thinking. We adopted the importance of skill-sharing, role-blurring and informality as we established our community mental health teams (CMHTs). We also, probably, absorbed the ‘drugs, sex and rock ‘n roll’ attitudes of the time. We are still all on first name terms!

This collaborative and democratic approach is one we rightly value and now take for granted. There were always inconsistencies (my memory of the early 70s was that the senior doctor was clearly the boss although that was never mentioned). The marked rise in the level of professional training in our colleagues (the arrival of clinical psychologists, graduate and post-graduate training for nurses etc) has put this convenient omission under some strain. Many CMHTs became quite uncomfortable places.

An early method of defusing this tension was to allow all team members to conduct new patient assessments (commonly seen as the high-status activity). Indeed, a UK 2005 policy ‘New Ways of Working’ actively promoted this, advising medical assessments to be reserved for ‘complex cases’.

The previous ‘gentleman’s agreement’ not to question why the doctor was paid twice as much as everyone else in these egalitarian teams has been abandoned. We now need to justify our position. We need to be clear what it is that we contribute, what cannot just as easily be contributed by another member of the team.

For me it is diagnosis. It is simply not true that we are all equally good at diagnosis. Indeed it would be remarkable if we were. Medical training is profoundly different to our colleagues – not just longer. It is a mistake for us to forget it. While medicine draws heavily on science, indeed on several sciences (physiology, pharmacology, sociology, psychology) it is not, itself, a science.

Simon Sinclair’s brilliant anthropological study ‘Making Doctors: An Institutional Apprenticeship’ describes how our training is based on repeated experience. We are exposed to as many patients as humanly possible. We have endless practice under supervision, and only a modest amount of theory and book-learning. In my twelve years from entering medical school to qualified specialist less than two of those years were devoted to full-time reading. We learn diagnosis, Sinclair points out, not by reading the criteria in a textbook, but by having symptoms and illnesses shown to us again and again in different patients (old patients, young patients, fat patients, thin patients, very ill patients, otherwise healthy patients). Over time we come to recognise them and can identify them in their manifold presentation , filtered through the endless range of human variation.

We are exposed to as many patients as humanly possible. We have endless practice under supervision, and only a modest amount of theory and book-learning.

Refining our skills in pattern recognition also teaches us a degree of humility. You don’t have to understand an illness to recognise it. It’s good, of course, if the treatment is logical and makes sense, but it doesn’t have to be. What matters is if it works. This pragmatic approach also teaches us, as Sinclair points out, to be able to operate in uncertainty. We don’t have to know for certain – every diagnosis is a hypothesis and to be tested with treatment. We look for the best fit – not a perfect fit. Just as diagnostic skills are acquired by endless practice, they need endless practice to remain sharp.

On two occasions as a head of service I have re-introduced the practice of doctors conducting assessments of all new patients. I had expected violent opposition but was surprised when none came. In well-functioning teams the doctor was usually respected for it anyway; in less happy teams it was seen as a way of holding them to account, ensuring they pulled their weight. After all the purpose of a multi-disciplinary team is not that we should all do the same thing. It is to combine our different skills to the same end of helping the patient.

Perhaps the most telling argument is that getting an assessment from the most senior doctor available is what we (as doctors) invariably seek when our family member is ill! If it is what is right for us and them, then so it should be for everyone else. □

Reference by request

  • Making Doctors: An Institutional Apprenticeship. Simon Sinclair. 1997.


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