How Psychiatrists Make Decisions

Abstract This book makes explicit the methodology used by experienced psychiatrists in making treatment decisions about individual patients. Traditionally such clinical reasoning has been tacit and learned largely by imitation during training. This is a problem at a time when psychiatry seeks to be scientific and evidence-based. The result has been a devaluation of clinical judgement. Instead, the dominance of evidence-based medicine (EBM) has left clinicians feeling that their decisions are credible only to the extent that they are applying results from research trials of groups of patients to their individual patients. Yet EBM provides no meaningful guidance in how to do this. Clinicians are told to fill the gaps using their clinical judgement, but that judgement is accorded very little evidentiary value. Through case studies, this book conducts a phenomenological exploration of how psychiatrists deliberate and shows that the methodology consists of constructing a model for each unique patient that is composed of a pattern of propensities and their interactions (POP models). Such models allow the rational incorporation of evidence and the formulation and testing of specific predictions, with mechanisms for revising models where needed. POP models parallel the strategies that cognitive scientists have uncovered studying the development of expertise across disciplines, and this understanding can be used to facilitate pedagogical strategies for trainees. Recent work in the philosophy of science further argues that such model construction is at the core of how all science is practised. As a result, the psychiatrist can have enhanced confidence in the epistemological credibility of their conclusions.