Thursday, May 30, 2013

Brooks on Psychiatrists As "Heroes of Uncertainty"

Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise.  His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology".  Psychiatry is certainly comparable to biology but not to physics.   And what is it about psychiatry that is unscientific?  The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme.  It is probably why many authors seek to equate psychiatry with the DSM.  The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry.  The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.  

Brooks characterization of the DSM shows a continued lack of understanding of this manual by  every journalist who writes about it.  There is practically no psychiatrist I know of who considers it to be authoritative.  Very few psychiatrists  actually go about their diagnostic business by reading through DSM criteria.  That activity would be limited to novices and medical students.    It is well known that only a fraction of the diagnoses listed are ever used in clinical practice.  After familiarizing themselves with the major changes, few psychiatrists will every open it again.   Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual.  The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it.  Despite all of the concern about the public impact - psychiatrists are the target audience here.  Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it.  I guess a lay person might be impressed, but I never met a psychiatrist who was.  

Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems".  That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist.   That technical knowledge is contained in a vast literature, much of it written by psychiatrists.  It is the reason that ongoing training and education of physicians is a career long commitment.  In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.

There is the associated question about whether physicians are scientists or not.  I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not.  That is quite different from suggesting that physicians are unscientific.  There are certainly not many physicians who are performing scientific experiments and publishing papers.  I suppose that you have to do that to be a professional scientist.  On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians..  I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year.  Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise".  There really is no art in medicine.  The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns.  They can apply that knowledge to patient care.  In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.

This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine.  My study of psychiatry finds it in neither of those locations.  There is a reason that psychiatrists need to go to medical school.  The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist.  Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine.   When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.   

Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences.  Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus.  I will give Brooks partial credit when he writes about the DSM.  Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible".  When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel.   But I also know that I am not rolling the dice or taking a leap of faith.   I am  doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.

George Dawson, MD. DFAPA

David Brooks.  Heroes of Uncertainty.  NYTimes May 27, 2013.

1 comment:

  1. Ann Kazarian, MDMay 30, 2013 at 1:23 PM

    Thanks, George
    Ann Kazarian