van Westen Maarten, Rietveld Erik, van Hout Annemarie, Denys Damiaan
Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.
Research Group IT Innovations in Health Care, Windesheim University of Applied Sciences, Campus 2, Zwolle, The Netherlands.
Phenomenol Cogn Sci. 2023;22(1):129-148. doi: 10.1007/s11097-021-09732-3. Epub 2021 Mar 9.
Despite technological innovations, clinical expertise remains the cornerstone of psychiatry. A clinical expert does not only have general textbook knowledge, but is sensitive to what is demanded for the individual patient in a particular situation. A method that can do justice to the subjective and situation-specific nature of clinical expertise is ethnography. Effective deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) involves an interpretive, evaluative process of optimizing stimulation parameters, which makes it an interesting case to study clinical expertise. The aim of this study is to explore the role of clinical expertise through an ethnography of the particular case of DBS optimization in OCD. In line with the topic of the special issue this article is a part of, we will also use our findings to reflect on ethnography as a method to study complex phenomena like clinical expertise. This ethnography of DBS optimization is based on 18 months of participant observation and nine in-depth interviews with a team of expert clinicians who have been treating over 80 OCD patients since 2005. By repeatedly observing particular situations for an extended period of time, we found that there are recurrent patterns in the ways clinicians interact with patients. These patterns of clinical practice shape the possibilities clinicians have for making sense of DBS-induced changes in patients' lived experience and behavior. Collective established patterns of clinical practice are dynamic and change under the influence of individual learning experiences in particular situations, opening up new possibilities and challenges. We conclude that patterns of clinical practice and particular situations are mutually constitutive. Ethnography is ideally suited to bring this relation into view thanks to its broad temporal scope and focus on the life-world. Based on our findings, we argue that clinical expertise not only implies skillful engagement with a concrete situation but also with the patterns of clinical practice that shape what is possible in this specific situation. Given this constraining and enabling role of practices, it is important to investigate them in order to find ways to improve diagnostic and therapeutic possibilities.
尽管有技术创新，但临床专业知识仍然是精神病学的基石。临床专家不仅具备一般的教科书知识，还能敏锐地感知特定情况下个体患者的需求。民族志是一种能够公正对待临床专业知识的主观性和情境特异性的方法。用于强迫症（OCD）的有效深部脑刺激（DBS）涉及优化刺激参数的解释性、评估性过程，这使其成为研究临床专业知识的一个有趣案例。本研究的目的是通过对强迫症中DBS优化这一特定案例的民族志研究来探索临床专业知识的作用。与本文所属特刊的主题一致，我们还将利用研究结果反思民族志作为一种研究临床专业知识等复杂现象的方法。这项关于DBS优化的民族志研究基于18个月的参与观察以及对一组专家临床医生的九次深入访谈，该团队自2005年以来已治疗了80多名强迫症患者。通过长时间反复观察特定情况，我们发现临床医生与患者互动的方式存在反复出现的模式。这些临床实践模式塑造了临床医生理解DBS引起的患者生活体验和行为变化的可能性。集体确立的临床实践模式是动态的，并在特定情况下个体学习经验的影响下发生变化，带来新的可能性和挑战。我们得出结论，临床实践模式和特定情况是相互构成的。由于民族志具有广泛的时间范围和对生活世界的关注，它非常适合揭示这种关系。基于我们的研究结果，我们认为临床专业知识不仅意味着熟练应对具体情况，还意味着应对塑造该特定情况下可能性的临床实践模式。鉴于实践的这种制约和促成作用，为了找到改善诊断和治疗可能性的方法，对其进行研究很重要。
