Risk and professionalism

In uncertain times for psychiatrists and for the medical profession in general, defining roles and responsibilities is proving to be a complex task. Yet, as clinicians grapple with multidisciplinary and multiagency teamwork, one expectation of consultant psychiatrists has become clear – their central role in assessing and managing risk. For many of us this is both challenging and uncomfortable. It is also under threat from ‘the growth of risk management strategies that displace valuable – but vulnerable – professional judgement in favour of defendable process’ (Power 2004: pp. 10–11).

Downie & Macnaughton (pp. 322–327) distinguish between theoretical and practical professional judgements. In addition to asserting ‘what is probably true or correct’ we have to decide ‘what we ought to do’. Such judgements are always made in conditions of uncertainty, albeit informed by the evidence base and ‘reasonable considerations’. Thornton (pp. 328–331) agrees that clinical judgement is ‘at the heart of good clinical practice’. The crux of the matter is seeing when ‘a general concept applies to an individual person’. Downie & Macnaughton outline further threats to professional judgement – the false securities of ‘objective’ reductionist approaches and an undermining of the professional role in a consumerist culture. But they also highlight how professional judgement may be safeguarded and developed. Knowledge and skills in diagnosis, treatment and ethics are vital but they pay special attention to attitudes. Here, ‘broad education … in humane values’ is essential to developing the necessary breadth of perspective, curiosity and flexibility of mind. Such a broad educational agenda is one to which Advances can make an important contribution by presenting the evidence, teasing out the ethical issues and practical implications, and featuring the medical humanities.

Our front cover accompanies the article by Lopez Gaston et al (pp. 344–353). This photograph, published with the patient's permission, is a vivid illustration of a less often considered risk – the unintended hazards resulting from compulsive hoarding. This is just one of the secondary risks relating to obsessive–compulsive disorder considered by Veale et al, my Editor's Pick.

Risk and OCD

Veale et al's article (pp. 322–327) brings together an authorship of uncommon bedfellows – practitioners working in young peoples' and in adult services, psychologists and psychiatrists, clinicians and academics. Such interdisciplinary collaboration is fully in the spirit of Advances. The authors inform us that, although ‘there are no recorded cases of a person with OCD carrying out their obsession’, numerous secondary risks derive from the meaning attached to intrusive thoughts and the response to them. One such risk, played out in therapeutic relationships, is the ‘transmission of obsessional worries from the patient to the clinician’. Few clinicians would not experience at least a frisson of anxiety and doubt if a patient with OCD who works with children asked them, ‘Are you 100% confident that my intrusive sexual thoughts are obsessional rather than something else?’.