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neuroleptic treatment. However,it has worked consultant. Meetings can become Laugharne's dilemma may be been observed in untreated populations focused on service needs and used as an approached by using concepts of decision and should not be a reason to bar opportunity to delegate work,to the analysis,a slowly evolving aspect of EBM. columns medication. detriment of training requirements. Roughly,a clinical decision process must Moncrieff & Smyth at least concede Appraisers can also fail to take a balanced include the patient's relative preferences that our patients may prefer to live in the approach,either concentrating solely on e.g. utilities),or better still,the values community. If we had at our disposal a the appraisee's strengths or by being that the patient assigns to such utilities. chance to keep them there in better overly critical. Only when a patient cannot do this,might mental health,surely this would lead to a In order to improve standards in this the clinician alone quantify these utilities. duty to facilitate this process. area,there needs to be appraisal of the In either case,the final decision may not appraisers themselves,and the provision necessarily favour the option best Reference of adequate training to facilitate such an supported by the external evidence. improvement. DIXON,L. B.,LEHMAN,A. F. & LEVINE,J. 1995) Conventional antipsychotic medications for Antony Gahan,Specialist Registrar,Drug Reference Schizophrenia. Schizophrenia Bulletin, 21,567^577. Dependency Unit,Homerton Hospital,Homerton Row,London E9 6SR SACKET,D. L.,ROSENBERG,W. M. C.,GRAY,J. A. M., et al 1996) Evidence-based medicine: what it is and *S. Llewellyn-Jones,Senior House Officer in what it isn't. British MedicalJournal, 312,71^72. Psychiatry, P. Donnelly,Consultant in Community Psychiatry,City and County of Swansea David Marchevsky,Consultant Psychiatrist, Community Mental HealthTeam,Gelligron,Gelligron Campbell Centre,StandingWay,Eaglestone,Milton Road,Pontardawe,Swansea SA8 4LU Evidence-slaved medicine Keynes MK6 5NG Sir: I would like to comment on an aspect Problems with appraisal of Laugharne's analysis of evidence-based medicine EBM) Psychiatric Bulletin, Sir: The National Service Framework for November 1999, 23,641^643). He states Halloween spooks and Mental Health highlights the need for that the philosophy underlying EBM schizophrenia rigorous performance management in consists of rational and measurable inter- services,and for the support and ventions that should prove beneficial to Sir: Many of us will have been involved empowerment of staff. The Health Secre- patients. This does not do much to resolve with or subjected to the ritual `trick or tary,in his recent document, Supporting the tension between EBM and user invol- treat' routines of the 31st October. I was Doctors,Protecting Patients underlined vement. If these principles are not inte- surprised to open the door to a group of that effective appraisal is an essential part grated to other basic concepts,then he 10^11-year-olds who had dressed up as of achieving those aims. However,at a has outlined the basis of what I call people with schizophrenia rather than the recent Appraisal Training Workshop for `evidence-slaved medicine'. more traditional ghosts,witches,demons, Specialist Registrars in Psychiatry,trainees' Sacket et al 1996) define EBM as ``the devils,grim reapers and so forth. I was reflections on their experiences of appraisal conscientious,explicit and judicious use of informed by their accompanying parent showed a wide variation in its quality. current best evidence in making decisions that they had some teaching at school Appraisal can be a positive experience, about the care of individual patients . . .'', about mental illness. They were suffi- especially when it is a dialogue that is and ``. . . external clinical evidence can ciently intrigued and terrified by what both respectful and honest. An effective never replace individual clinical expertise they had heard to enact their impressions appraiser will provide a structured way to andit is this expertise that decides whether in the above way. address issues,building on the trainee's the external evidence applies to the indi- While there are many ways in which previous experience. Concerns need to be vidual patient at all,and,if so,how it should public awareness campaigns can be acted on as soon as possible and followed be integrated into a clinical decision''. misunderstood,I had not previously come up. There should also be an opportunity Laugharne stresses the extent to which across this one. I have written to the local to explore areas of weakness,without medicine must catch up with aspects of director of education with this feedback, fear that the trainee's reference will be non-linear dynamics and quantum but thought that the College may also like adversely affected. mechanics. However,realising the obser- to be aware of this particular interpreta- Trainees have also had negative experi- vations made by Poincare¨19th century) tion. ences. At worst,appraisal has been non- and Planck 20th century) might not help Gianetta Rands,Consultant in Old Age Psychiatry existent,or merely `going through the him much here. He may find that the and CollegeTutor Camden & Islington Community motions' with an unmotivated appraiser. observations about games that Bayes Health Services NHS Trust,A8,4th Floor,Holborn Trainees may feel reluctant to insist on made in the 18th century are much more Union Building,The Archway Campus,Whittington regular meetings with an already over- useful. Hospital,Highgate Hill,London N19 5NF the college

Honorary Fellowships eminent in psychiatry or in allied or graduate Educational Services,to whom connected sciences or disciplines or has nominations for the Honorary Fellowship Nominations to the College's Honorary rendered distinguished service to should be sent by 1 September 2000. Fellowship will be discussed at the humanity in relation to the study, Such nominations must contain recom- October meeting of the Court of Electors. prevention or treatment of mental mendations by no less than six Members The regulations of the College state illness or to subjects allied thereto or of the College,and include full supporting under Bye-Law Section VI that: connected herewith or has rendered documentation. ``Subject to the Regulations the College notable service to the College or to may elect as an Honorary Fellow any theAssociation.'' Anne Dean,Head of Postgraduate Educational person,whether or not he is a member Nomination forms are available from Ms Services,Royal College of Psychiatrists,17 Belgrave of the medical profession,who either is Beverley Fiddimore,Department of Post- Square,London SW1X 8PG

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