The New Year: Time for “Pragmatic Pluralism”

I was happy to see an essay from Dr. Ronald Pies, MD, Editor in Chief Emeritus of Psychiatric Times today, entitled “Psychiatry’s Solid Center,” published in the December 2015 issue of Psychiatric Times. I know it hurts to even think about generating another username and password, even if registration is free, but I’m recommending it.

What Dr. Pies means by the “solid center” of psychiatry are those who believe that it’s all about “both/and” rather than “either/or” (this used to be the subtitle below my blog’s main title of The Practical Psychosomaticist) in the practice of psychiatry. That means emphasizing the equal importance of applying both psychopharmacology and psychotherapy rather than excluding one or the other in helping patients heal. He calls it “pragmatic pluralism.” There are many comments after the article, some of them unbelievably trollish (I imagine, because they were edited). Anyway, the exchange between Ron and I was cordial, as I think it ought to be as we enter the new year:

Hi Dr. Pies,

I really enjoyed this piece and many thanks for the reminder that a lot of psychiatrists strive for balance between psychotherapy and psychopharmacology.

When you mentioned Dr. Paul McHugh, it immediately made me think of the book he and Philip Slavney wrote, The Perspectives of Psychiatry, which was followed by Systematic Psychiatric Evaluation by Chisolm and Lyketsos. It’s been a part of our residency program curriculum for years.

I see the disease, behavior, life story, and dimensional perspectives every day in my practice as a general hospital psychiatric consultant.

Happy New Year!

James J. Amos, MD
Clinical Professor
Department of Psychiatry
The University of Iowa Hospitals & Clinics
200 Hawkins Dr., 2880 JPP
Iowa City, Iowa 52242
Blog: The Practical Psychosomaticist

– See more at:

Many thanks for the kind note, Dr. Amos, and for the reminder of the classic text by Drs. McHugh and Slavney. I’ll also mention the book by my colleague, Dr. Nassir Ghaemi (The Concepts of Psychiatry), which has a foreword by Dr. McHugh. All these scholar-clinicians view psychiatric illness from a pluralistic and broad-based perspective–I.e., from the “solid center” of my essay.

Readers of Psychiatric Times will note that Dr. Amos is an exemplar of such pluralism, as seen in his posting at :

There, Dr. Amos addresses the importance of “…integrating the practical with the theoretical, medicine with psychiatry, classical poetry with a sense of humor, and the good sense not to take yourself
too seriously.”

Amen to that, Jim, and a Happy New Year to you, too!

Ron Pies MD

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I enjoyed Ron’s article even more because I had been reading about physician burnout recently.

The Mayo Clinic Proceedings and the Psych Congress Network articles speak to the same barriers to achieving better work to life balance, especially from loss of autonomy. While the authors don’t mention Maintenance of Certification (MOC) specifically, they mention over-regulation and in my book that points to the wasteful MOC debacle. I think many of us focus on this issue because it seems the one we can most likely influence. I believe the parallel to Ron’s article is that the MOC problem seems related to the same inherent flaw in dualism–board leaders seem to be obsessed with making managers out of leaders and making leaders out of managers.

We need both. However, there are only so many hours in the day and if busy doctors have to take time away from real patient care to fiddle with check boxes, then someone has lost sight of the forest for the trees. This is a common problem arising from excessive preoccupation with management.

Those of us who are trying to practice in Psychiatry’s solid center (trying to be “pragmatic pluralists”), need more time with our patients and less time with wacky fluff like Part IV of the American Board of Psychiatry and Neurology (ABPN) MOC, especially the Performance in Practice (PIP) modules, which are often not relevant to our practices. Look, my health monitor app on my brand-spanking new smartphone tells you how much I need extra paperwork:

Smartphone Health App
Smartphone Health App

I am a consulting psychiatrist and my office is the entire general hospital. I walk back and forth across the facility several times a day, averaging 2-3 miles, climb up to 21 floors, and use the medical literature daily to guide my practice as I try to figure out the medically safest, most humane, and most humanistic way to help persons heal. I believe in the core competencies–just ask my residents.

Core Competency Pizza
Core Competency Pizza

Want to know how many bedside psychotherapy modules there are on the ABPN web site? Exactly none. That’s right; it does nothing to support the practice of pragmatic pluralists. And that is despite the importance that real leaders in psychiatry ascribe to psychotherapy.

And can we access the new MOC Clinical Advisory Committee of board-certified psychiatrists and neurologists to let them know what rank-and-file doctors think of the MOC? It’s not immediately obvious and some of us will sooner or later get the idea that the committee members might have been hand-picked to support the MOC regardless of its obvious flaws.

Let’s not forget the ABPN Letter to Diplomates and the ABPN-Letter (1). We are clearly unhappy about the powerlessness (read “loss of autonomy”) that the board system has imposed on hard-working physicians who are increasingly suffering from burnout, incredibly, because we want to provide the best care for our patients but are hindered by the bewilderingly unimportant and tedious PIP pettiness.

We’re better than that. Patients deserve better. We need to have a vote in who the managers are who seek to serve as board executives. And these managers need to be pragmatic pluralists if they want to be viewed as our leaders.

2 thoughts on “The New Year: Time for “Pragmatic Pluralism”

  1. Thanks again for the call-out to my article, Jim, and for your continued good efforts in behalf of pragmatic pluralism. I have retired from clinical practice, but I “feel your pain” over the MOC debacle! Let’s hope the new year brings better things to us and to our patients.

    Best regards,

    Ronald Pies MD

    Liked by 1 person

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