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Editorial: Decision Making By Psychiatrists: Principles

In managing a psychiatric condition, a core aspect is decision making where the clinicians – by virtue of their experience, training, knowledge and expertise – make decisions. Increasingly in psychiatry, a clear gulf has emerged between biological management and psychological aspects (Luhrmann 2000). In physical conditions, clearly the sick organ produces a sick body, which is then treated by the physician. In psychiatry, too the condition, based in the mind, is often treated as if it were a condition affecting the body and requiring physical treatment. Some of these distinctions often create problems in decision making in psychiatric conditions. Delayed diagnosis can be caused by the prolonged prodrome of certain psychiatric conditions, but more importantly the clinicians themselves may follow an erroneous pathway. In a study of delayed and missed diagnosis, Gandhi et al (2006) found that even infections, fractures and myocardial infarcts were most likely to be missed, especially in physicians’ offices rather than emergency rooms. The reasons for this are not entirely clear but can be attributed to a number of factors such as lack of vigilance, failure in judgement and a lack of knowledge about these very common conditions. Misdiagnosis in physical conditions is not uncommon. In four different eras Wilhelm & Schaffi (1996) looked at levels of misdiagnosis in autopsy cases and found that in each decade from 1959 the level of misdiagnosis remains around 10% even though autopsy rates had dropped by nearly 50%. Patients’ medical history and physical examination played an important role in reaching a diagnosis. Cognitive errors in diagnosis are a manifestation of a fallacy in clinical cognition or clinical reasoning (Kassirer & Kopelman 1989). According to these authors, cognitive diagnostic errors are due to faulty triggering, faulty context formulation and faulty information gathering and processing. Faulty verification of a faulty hypothesis can only add to the confusion. Similar triggers can be found in psychiatric consultations. Reidelmeier et al (2001a) noted that while giving a history, patients made errors because of mistakes in comprehension, recall, evaluation and expression. Comprehension changes according to language and conversational and cultural norms. These authors observe that use of ambiguous language, failures of memory, inconsistent expectations and social comparisons all contribute to the possibility of misdiagnosis or delayed clinical diagnosis. Another factor along with age is the gender of the patient and of the diagnostician. Rotter & Hall (2004) suggest that there are clear gender differences in information gathering and information sharing. They found that female physicians spend more time talking with patients and discussed higher levels of psychosocial or socioeconomic issues. They also noted that gender plays a different role across different specialities.