November 14, 2012

Clinical Excellence in Psychiatry: A Review of the Literature

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Margaret S. Chisolm, MD

Johns Hopkins University School of Medicine, Baltimore, Maryland


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.


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

Category: Mental Illness
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7 thoughts on “Clinical Excellence in Psychiatry: A Review of the Literature

  1. In my opinion, I am clinical pharmacist, there is no clinical excellence in psychiatry. There is clinical expertise or clinical experience , but there are very few chances to talk about clinical excellence and even less if we talk about clinical evidence translation to practice. I think there is an urgent need to discuss about this topic.
  2. There is a lack of information between what is written in the CG82 from NICE and what really happens in clinical practice. Can we discuss why this happens?
  3. Dr Chisholm , I am there with you and I have not seen passion in most doctors as they just keep working and adding medication instead of listening to some stories patients share with us .
  4. As a patient, I am exceedingly fortunate to have a psychiatrist who by the definition in this article, is a paragon of clinical excellence.
    Every single one of the members of the support group I attend doesn’t have a doctor who even remotely comes close to my doc. Their symptoms aren’t managed, the docs talk about things other than the patients’ needs (WAY off-topic), and see them for only 10-15 minutes. My doc is always on-topic and typically spends 1/2 hour with me and really listens and gives me credit for my intelligence. I have to drive 70 miles one-way to see him, but it’s more than worth it (I have ultradian-cycling Bipolar Disorder with mixed states). He’s kept me out of the hospital for over 20 years. He is an independent practitioner; as such, he often will charge me very little, or nothing at all. (I live on SSDI).
    For the sake of every mentally ill patient, I implore PGYs and fellows to push for clinical excellence. These are human lives, folks, and the ripple effect of substandard care is profound, affecting lives beyond the scope of treating the patient.
  5. My colleagues we can develop our clinical work by developing our clinical practice in terms of clinical interviews, ethics and better clinical performance. I am from Somalia, I find clinical skills the strongest tool in my career
  6. efforts at achieving excellence have at least temporarily run aground on EHRs,for me. hope as I get more proficient,that I can shift my focus back to the patients’ needs= THAT is excellence
  7. Dr Chisholm I totally endorse your comments regarding clinical excellence in psychiatry.
    Passion, honesty and curiosity are some attributes of excellence.
    Thank you.

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