Abstract
Dear Sir,
Russell Gibson’s letter ‘Expert leadership’ 1 makes two main points. It argues for training in leadership, in psychiatry, and it argues for quality improvement over audit. The first suggestion is incontestable. Psychiatrists, like their general medical confrères, have lost the political high ground. They no longer run the show. That certainly needs correction.
The second point depends on the definition of quality improvement. Gibson infers that quality improvement means improvement in treatment, and treatment service delivery. But quality improvement equally means quality clinical audit. For audit can be dichotomised between administrative audit – bean counting – and clinical audit. The former now essentially excludes the latter. Clinical audit has been virtually abandoned. 2
Clinicians generally comply with an administrative audit, but rarely conduct a true clinical audit of their personal or service caseload. The crucial nuances of time, place and person, the local social and cultural conditions in ontogeny and phylogeny that should inform personal and local service delivery, are neglected. Academic epidemiology examines generic factors in individuals and populations in place and over time. But the gap between the clinic and the laboratory needs to be bridged by clinical ‘epidemiological’ audit.
Quality improvement should be based on local audits of patient numbers, and patients types according to diagnosis and demography, at the very least. Prevailing local conditions should also include sociocultural factors, some present-centred, and some ongoing, and historical. Unless these are taken into account, there can be no true quality improvement. This principal was inferred, vis-à-vis phylogeny, in an article that I penned on schizophrenia in Mannheim. 3 The diagnostic and epidemiological findings of the author, Hafner, in no small part reflected the local conditions in Mannheim, Germany, most notably, the history of Nazism and World War II, and the history of immigration from Eastern Europe and Asia. I penned a further article and a comment that make the comparable case for ontogeny, vis-à-vis diagnosis in suicidology (see http://bjp.rcpsych.org/content/205/2/120.e-letters#suicide-ontogeny-and-phylogeny). 4
Interestingly, the tendency to eschew clinical audit at the expense of quality improvement mirrors the general tendency to eschew diagnosis over treatment. This is the prevailing neglect. Diagnosis, including diagnosis in epidemiology, has been reduced to a cipher.