Clinical Excellence in Psychiatry: A Review of the Literature

My colleagues and I began our inquiry into whether a paper on clinical excellence in psychiatry was warranted by reviewing what had been published previously on this topic. It turned out that—although the topic had been broached by a few psychologists—very little had been written about clinical excellence by psychiatrists. The bulk of the work by psychiatrists had focused on clinical competence, a topic of great appeal to our profession’s accreditation organizations but lacking in vision and inspiration. Clinical excellence is what most patients hope to find in their psychiatrists and is what most psychiatrists aim to achieve. Competence, it seems to me, is a very low bar. Clinical excellence is the goal.

With few commentaries and no evaluative studies, case reports provided an alternative way to review the literature in this area. But these, too, were surprisingly scant. It seems that fewer and fewer journals are publishing case reports. Editors are looking for articles that reflect a higher level of evidence and, perhaps, garner more reprints and citations than case reports do. But I’m still a big fan of case reports as a way of framing both clinical discussions and research questions. They also provide an opportunity for psychiatry trainees and junior faculty to try their hands at writing. And, by definition, case reports keep the reason we all do what we do—the patient who needs our help—front and center.

So, for our review, we looked to see whether the domains of clinical excellence, as established by the Miller-Coulson Academy of Clinical Excellence at Johns Hopkins, were touched on in case reports. If so, we could surmise that the domains of clinical excellence must be relevant to psychiatry. We reviewed case reports for the following domains of clinical excellence:

• communication and interpersonal skills
• professionalism and humanism
• diagnostic acumen
• skillful negotiation of the health care system
• knowledge
• scholarly approach to clinical practice
• exhibiting a passion for patient care
• explicitly modeling mastery to medical trainees
• collaborating with investigators to advance science and discovery

We found psychiatric case reports that each touched on at least one of these domains.

Most amusing to me was how challenging it was to find a case report in which a passion for patient care was exhibited. As a group, contemporary case reports seem to have had most of the passion drained out of them. I suppose this helps them to appear more scientific and thus more acceptable for publication in a peer-reviewed journal. Or perhaps the process of appropriately protecting a consenting patient’s identity leeches all life from the report. Whatever the reason, we had to go back to the Victorian age to find an example of a passionate case report, written by none other than Sigmund Freud¹. He is the all-time master of the psychiatric narrative. His skill at writing is one of the reasons that Freud’s ideas captured so many psychiatrists’ imaginations, and his passion for patient care is part of his reputation of clinical excellence.

The field of psychiatry—and our patients—would benefit from raising the bar from clinical competence to clinical excellence. We also need more publication outlets for case reports and many more psychiatrists who are willing to reveal their passion for patient care!

Financial disclosure:Dr Chisolm had no relevant personal financial relationships to report.

Reference

1. Freud, Sigmund. The Freud Reader. Gay P, ed. New York, NY: W W Norton & Co; 1989.​