‘Rational’ Practice Involves Irrationality

In the January issue, Dr. H. Paul Putman nicely defended his use of the word “rational” in the article titled "Rational Prescribing Is Caring Psychopharmacology". In addition to the important point he makes—that being thoughtful and informed when making medical decisions is an essential feature of “caring psychopharmacology”—we should keep in mind that evidence-based medicine, as originally conceived, includes the patients’ circumstances and preferences.

Writing in the November 4, 1992, JAMA, Gordon Guyatt, M.D., M.Sc., and colleagues explicitly spoke of “sensitivity to patients’ emotional needs,” “understanding patients’ suffering,” and “using the techniques of behavioral science to determine what patients are really looking for from their physicians” ("Evidence-Based Medicine—A New Approach to Teaching the Practice of Medicine"). Prof. David Sackett and colleagues stated this very clearly in a January 13, 1996, BMJ editorial: “Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care” ("Evidence based medicine: what it is and what it isn't").

Psychopharmacologists and psychoanalysts alike surely agree that “the irrational” is a crucial component of our work—particularly coming to grips with our own biases and misinterpreted experience, as well as skillfully approaching our patients’ fears and confusion. Someone once taught me that the core of psychiatry is “unscrewing the inscrutable” (a phrase lifted from Ezra Pound, who got it from a fellow asylum inmate).

To be truly rational physicians, we must often expertly incorporate the irrational. Our professional tolerance for ambiguity and irrationality distinguishes us from other physicians and, with our patients, as Dr. Putman so nicely put it, requires “a fully engaged partnership.” ■

JOHN D. WYNN, M.D.

Seattle, Wash.