Original Article
Evidence-Based Medicine in the Education of Psychiatrists
Vinod Srihari, M.D.
Objective: Evidence-based medicine has an important place in
the teaching and practice of psychiatry. Attempts to teach evi-
dence-based medicine skills can be weakened by conceptual con-
fusions feeding a false polarization between traditional clinical
skills and evidence-based medicine.
Methods: The author develops a broader conception of clinical
expertise consisting of three tasks, clarifies the role of evidence-
based medicine, and explores the implications for teaching and
practice.
Results: Evidence-based medicine is an essential tool that en-
ables clinicians to assess causal explanations in etiology, risk, or
prognosis, or to compare treatments.
Conclusion: An explicit and inclusive conceptualization of
clinical skills can provide a framework to implement and assess
curricular efforts to teach evidence-based medicine.
Academic Psychiatry 2008; 32:463–469
Received January 16, 2006; revised May 6 and September 4, 2006,
and June 19, 2007; accepted June 27, 2007. Dr. Srihari is an Assistant
Professor in the Department of Psychiatry, Yale University School of
Medicine, in New Haven, Conn. Address correspondence to Vinod
H. Srihari, M.D., Psychiatry, 34 Park St., CMHC, New Haven, CT
06519; vinod.srihari@yale.edu (e-mail).
Copyright 䊚 2008 Academic Psychiatry
Academic Psychiatry, 32:6, November-December 2008
“ . . . The clinician who becomes adept at scientific clinical
examination and reasoning may no longer need to preserve
irrational barricades of the intellect to preserve his old ‘art’
against apparent assaults from the new ‘science’ . . . one of
the main purposes of improving science in the clinical ex-
amination . . . is to separate the false art from the true.”
—Alvan R. Feinstein (1)
Evidence-Based Medicine in the Residency
Curriculum: Worth the Trouble?
Evidence-based medicine (EBM) has been described as
a “paradigm shift” in the practice of medicine. A seminal
1992 paper (2) described the traditional paradigm as re-
lying excessively on unsystematic clinical observation,
pathophysiologic theory, and content expertise. This was
contrasted with the proposed evidence-based paradigm of
clinical practice. The latter advises caution in the absence
of systematic study, the necessity but insufficiency of path-
ophysiologic theory, and the need to understand certain
“rules of evidence” in applying clinical literature to patient
care. Goldner and Bilsker (3) reminded us of the antiquity
of this distinction and advocated a similar shift for clinical
psychiatry toward a more balanced emphasis on techne, or
“abstract laws governing types of patients,” in an area pre-
viously dominated by phronesis, or “clinical judgment in a
particular case.”
Several prominent voices have called for a similar move
in residency training. Evidence-based medicine has been
proposed as a “core principle” to guide the reform (4) and
assessment (5) of residency education. Indeed, a compo-
nent of the core clinical skills required by the Accredita-
tion Council for General Medical Education (ACGME)
(Table 1) closely parallels the steps of clinical decision-
making articulated in EBM manuals (Table 2).
A reasonable assumption supporting such proposals is
that teaching EBM skills will facilitate the translation of
emerging clinical research into practice (6) and thereby
improve clinical outcomes. However, this claim is difficult
to substantiate empirically, and EBM-guided approaches
to practice have been met with controversy. An exhaustive
review of such criticisms (7) includes concerns that this
approach tends to devalue clinical expertise, ignores the
http://ap.psychiatryonline.org 463
EBM IN THE EDUCATION OF PSYCHIATRISTS
TABLE 1. Practice-Based Learning and Improvement1
Residents are expected to:
• analyze, practice, experience, and perform practice-based
improvement activities using a systematic methodology
• locate, appraise, and assimilate evidence from scientific
studies related to their patients’ health problems
• obtain and use information about their own population
of patients and the larger population from which their
patients are drawn
• apply knowledge of study designs and statistical methods
to the appraisal of clinical studies and other information
on diagnostic and therapeutic effectiveness
• use information technology to manage information,
access online medical information, and support their
own education
• facilitate the learning of students and other health care
professionals
1
Accreditation Council for General Medical Education:
ACGME Outcome Project. Available at http://www.acgme.org/
outcome/comp/compFull.asp
complex realities of patients’ presentations, and promotes
a “cookbook” approach to practice. Critics in psychiatry
TABLE 2. The Five Steps of Evidence-Based Medicine1
EBM Step
1. ASK a focused clinical question (i.e., convert a mystery into a ‘‘Does marijuana increase the risk of psychosis in a young person
problem)
2. ACCESS the best available evidence (i.e., consider the study
design most appropriate to the question)
3. Critically APPRAISE the evidence (e.g., Is it valid? Is it
important? Is it applicable to my patient?)
4. APPLY the evidence (e.g., Can I integrate the probabilistic
results with information gained from empathic and interpretive
work with this patient?)
5. ASSESS the outcome in this patient (e.g., Did the intervention The patient continued to use marijuana, although with some
succeed?) or return to step 1 (i.e., Are there other questions?)
1
Del Mar C, Glasziou P, Mayer D: Teaching evidence-based medicine. BMJ 2004; 329:989–990
Addington J: Cannabis use increases the risk of young people developing psychotic symptoms, particularly if already predisposed.
Evid Based Ment Health 2005; 8:87
Henquet C, Krabbendam L, Spauwen J, et al: Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic
symptoms in young people. BMJ 2005; 330:11
464 http://ap.psychiatryonline.org
have also pointed to the inadequacy of the DSM-IV di-
agnostic system, the problem of unpublished evidence, and
the lack of representativeness of study participants (8, 9).
There is a dual irony in this very old controversy. First, the
prominence of techne, in the explicit language of EBM, has
sparked off useful criticism of simplified, data-driven ap-
proaches to practice. This has resulted in a clearer artic-
ulation of phronesis. Second, attacks on so-called “evi-
dence-based” recommendations often articulate sound
concerns about the validity, size, precision, and general-
izability of published evidence. These are concepts that
EBM is designed to teach. Meanwhile, the rapid accu-
mulation of published evidence only raises the stakes for
those wishing to make the best possible clinical decisions.
This article takes this reality as a point of departure:
there is a need for more, not less, pedagogic effort to en-
able trainees to understand the terms of this debate, wade
through the clinical literature, and learn to make indepen-
dent clinical decisions. After all, most clinicians would
agree that keeping up with the published evidence is simply
a part of sound clinical practice. The question taken up
Example
without a previous history of mental illness?’’
Consult a librarian to look for prospective cohort studies, or
systematic reviews of the same, that follow young people after
exposure to marijuana.
See Table 3 for worksheet and Addington J (2005) for a sample
appraisal of the selected study (Henquet et al, 2006), which
addresses the first two questions. Because the patient has no
known predisposition to psychosis, this study indicates a
moderately increased risk: perhaps as little as 1.13 or as much
as 2.5 times the ‘‘average risk’’ over the next 4 years. Also,
reducing the frequency of marijuana use to less than once a
month could decrease the risk by more than half.
The patient was engaged in a discussion of the above risks in the
context of his desire to attend college. Using a motivational
interviewing approach revealed several costs he was already
suffering from his daily use, including reduced socialization with
peers.
reduction in frequency. He agreed to return for periodic follow-
up in the clinic to monitor for adverse effects on his mood and
cognition, concerns he acknowledged sharing with his parents.
What is the ‘‘average risk’’ of developing psychosis in a young
male with no known risk factors? (Return to step 1.)
Academic Psychiatry, 32:6, November-December 2008

here is not whether but how to envision training toward
such self-directed education within a residency curriculum.
The challenges of implementing EBM in psychiatric
education arise from pragmatic and conceptual barriers.
In the first category are commonly reported factors such
as a lack of time and appraisal skills (10) that limit the
opportunities for residents to acquire competence in the
steps of EBM. Several creative classroom and bedside
teaching strategies (11–13) and case studies modeling
“real-time” decision making in psychiatry (14–16) have
been published to address this abiding challenge for busy
clinicians.
In contrast to the attention paid to these important bar-
riers, conceptual confusions have been neglected and will
be the focus of what follows. These confusions can derail
curricular efforts. For example, extended EBM-inspired
classroom discussions about meta-analyses or confidence
intervals can unwittingly convey the impression that non-
measurable aspects of clinical work are best relegated to a
mystical and, by implication, less respectable realm. Edu-
cators in EBM have also described trainees facing an un-
comfortable dissonance between the gratifying certainties
offered by the traditional paradigm and the probabilistic,
provisional answers provided by the evidence-based para-
digm (17). Although the EBM model advocates “integrat-
ing the best evidence with clinical expertise and patients’
values” (18), the actual practice of techne and phronesis
can seem to be worlds apart. Trainees are then vulnerable
to facing a false choice between two caricatures of prac-
tice. On the one extreme is the “intuitive” practitioner,
impervious to the fuss over evidence, and on the other is
the “highly numerate medical [academic, who] belittles
the performance of experienced clinicians using a com-
bination of epidemiological jargon and statistical sleight-
of-hand” (19).
Curricular efforts would thus benefit from an explicit
account of where EBM skills fit within broader educational
goals. An inclusive notion of clinical expertise is offered
here as one such goal. The project of moving toward this
goal can release trainees from misguided battles between
techne and phronesis. Both can then be incorporated in a
model of reflective clinical practice that acknowledges un-
certainty yet facilitates decisions made with the best avail-
able evidence. What follows is an attempt to step back and
recover a workable notion of clinical expertise for psychi-
atry; to situate EBM as a vital, albeit limited, part of this
notion; and to invite the reader to reflect on the implica-
tions for residency education and continuing professional
development.
Academic Psychiatry, 32:6, November-December 2008
SRIHARI
Two clarifications are necessary before proceeding.
First, EBM is used here in its original sense: a systematic
approach to clinical uncertainty for the individual clinician
who wishes to apply the best available evidence to everyday
clinical acts such as diagnosis, prognosis, etiologic specu-
lation, or treatment (Table 2). Teaching EBM thus sup-
ports, but is distinct from, the work of disseminating em-
pirically supported interventions or “evidence-based
practices” in a health care system. The latter is better dis-
cussed within a framework of change management or qual-
ity improvement (20). Second, this article is intended as a
conceptual background for, rather than a detailed descrip-
tion of, a curriculum.
Clinical Expertise: Practicing the Tasks of
Empathy, Interpretation, and Science
What is clinical expertise? Scholars have offered several
distinct notions of professional expertise that highlight ele-
ments such as technical skill, the ability to apply general
concepts, and the ability to reflect on and take a critical
stance toward one’s own practice (21). Others have warned
of the risk of paying too much attention to individual and
cognitive aspects of clinical expertise and ignoring factors
in the clinical environment—such as the availability of ex-
perienced collaborators—that can aid or limit effective-
ness (22). Certainly, the project of clarifying what makes
for “expert” practice is far from over and is reflected in
clinical legends of masterful diagnoses or interventions
that stand beyond educational recipes. In this light, what
follows is a limited, workaday conception of clinical ex-
pertise that should be judged for its ability to contextualize
EBM within psychiatric training.
Frank Fish (23) articulated three conceptually distinct
psychologies, interpreted here as tasks, faced by psychia-
trists in caring for patients. His own words are offered to
introduce the tasks of empathic, interpretive, and scientific
psychology.
The Empathic Task
“By means of introspective knowledge of our own behavior
and practical experience of the behavior of others, we de-
velop a special body of psychological knowledge which can
be called Empathic Psychology” (23).
Psychological knowledge derives from the first task of the
clinician trainee: to actively appreciate the idiosyncratic
connections among thoughts, feelings, and actions that
constitute another person’s mental universe. We will re-
main puzzled with a patient’s behavior (e.g., a man who
does not adhere to an antipsychotic that previously re-
http://ap.psychiatryonline.org 465
EBM IN THE EDUCATION OF PSYCHIATRISTS
lieved distressing hallucinations) without eliciting how the
patient came to this decision (e.g., his fear that the medi-
cine will make him less vigilant toward a neighbor who he
is convinced is spying on him). Supervised exposure to a
variety of patients can strengthen this empathic acumen.
However, we are quickly called to its limits: even the most
empathic listeners can only struggle to grasp experiences
that are qualitatively alien to them (e.g., psychotic hallu-
cinations, melancholic depression, or primary delusions).
Descriptive psychopathology, or published accounts of the
varieties of experience in mental illness (24), are thus es-
sential for the trainee to advance in this task, but clinicians
are still limited by what the patient censors (consciously or
not) from the dialogue. Clinician-trainees can proceed by
applying themselves to the next “task.”
The Interpretive Task
“Interpretive Psychology . . . [is that in] which the ideas
which have been obtained by empathizing with the patient
are formulated in terms of some general theory which has
been derived from neurophysiology, neurology, philosophy
or mythology” (23).
It is not enough to elicit a detailed description of a pa-
tient’s subjective landscape. In order to act, the clinician
must sift through this rich and diverse database with the
help of organizing theories. This is the second, or inter-
pretive, task. Leston Havens (25) described four interpre-
tive models, each with a distinct view on what constitutes
relevant data. This notion of having available several “per-
spectives” has also been elucidated by McHugh and Slav-
ney (26). Trainees can learn to apply distinct theoretical
points of view, selectively highlight clinical data, and to
formulate discrete interventions. For example, an em-
pathic approach (the first task) can elicit a rich account of
the fears and experiences of a patient, which can be sifted
(the second task) for evidence of a disease, such as a
chronic psychotic disorder, with its characteristic symp-
toms, course, and exacerbating factors. Additionally, a sec-
ond theoretical perspective that focuses on the patient’s
fantasies and goals in the context of his or her narrative,
or “life story” (26), can be invaluable in engaging the pa-
tient in psychotherapy. Trainees can also attempt to locate
the patient’s personality traits along a continuum so as to
better understand coping patterns to particular stressors.
This pluralistic application of multiple interpretive mod-
els is championed by Ghaemi (27), and its proposals are
worth examining. First, no one perspective or metaphor,
be it neurobiological, behavioral, or existential, can claim
466 http://ap.psychiatryonline.org
a complete account of human predicaments that present
for clinical attention. From this follows a need for the
trainee to become familiar with several approaches. Sec-
ond, this pluralism discourages an “anything goes” eclectic
approach, asserting that in most cases one perspective may
be more relevant and powerful than another. For example,
a behavioral perspective might offer more leverage than a
psychodynamic perspective in the initial approach to an
active alcohol addiction. The trainee must therefore pri-
oritize which theoretical approach is most relevant to the
particular predicament at hand. Third, there must be ex-
plicit awareness of particular strengths, weaknesses, and
predictions when a particular theory is being applied. This
alerts the trainee to appraise the empirical support for the
theoretically driven clinical choices and to monitor out-
comes. Such an appraisal is the substance of the third task.
The Scientific Task
“Empathic and interpretive psychology must be clearly dis-
tinguished from scientific psychology . . . which investigates
animal and human behavior in a scientific way and estab-
lishes rules and laws” (23).
The unique nature of the scientific task is best illustrated
with the concepts of Understanding (verstehen) and Ex-
plaining (erklaren), first translated for psychiatry by Karl
Jaspers (28). The work of Understanding is the clinician’s
task of comprehending the unique subjectivity of the in-
dividual patient. It rests on the premise that “behavior
means something, that is, it arises with internal consistency
from psychological events” (24). It can be made opera-
tional for trainees by teaching and guided practice in the
first two tasks. Explanation, in contrast, seeks a vantage
point outside of the patient’s subjective world and attempts
to evaluate causal connections relevant to clinical phenom-
ena.
For example, one young man in our clinic, with no pre-
existing psychotic disorder, insisted on continued daily use
of marijuana for its “calming” effects. This was a source
of considerable distress to his parents, who had read media
reports of a possible risk for psychosis and asked for a
clinical opinion. This raised the question about his per-
sonal risk for psychosis. Although two events might be as-
sociated—in this case, the use of marijuana and the initi-
ation of psychotic symptoms—the judgment of whether
one causes the other cannot be based solely on an empathic
interpretation of the patient’s experiences. We need here
to engage in “scientific psychology,” or the third task.
The trainee can be supervised through a systematic ap-
Academic Psychiatry, 32:6, November-December 2008

proach to this question (presented in Table 2). A detailed
account of this process has been described elsewhere by
myself and other authors (14, 15), and each step presents
opportunities to teach distinct knowledge and skills. For
example, the second step would include a knowledge of
“secondary,” or preappraised, sources, such as the journals
Evidence-Based Mental Health or Clinical Evidence, and the
use of search strategies which attempt to maximize the
rigor and minimize the time spent in trying to find relevant
information (15). For the third step, the trainee could be
guided to fill out the appropriate appraisal worksheet from
an EBM manual (29) (Table 3) or refer to a secondary
journal, such as Evidence-Based Mental Health, where the
article of interest has been appraised in a brief, structured
format (30). The trainee is urged to focus on three ques-
tions: how valid, how important, and how applicable are
the results? The subsequent steps four and five are sum-
marized in Table 2. This process often leads to further
questions that can be prioritized (31) based on clinical ur-
gency, ubiquity, or interest, and cycled through the same
steps. This can add both to the trainees’ knowledge and
confidence in seeking out answers.
TABLE 3. Sample Appraisal Worksheet for an Article
about Harm1
1. Are the results valid?
• Did the two groups begin the study with a similar
prognosis or were there significant baseline differences?
• Does the report demonstrate similarity in all known
determinants of outcome and, if not, was this adjusted
for in the analysis?
• Were the participants who were exposed to the harmful
agent equally likely to be identified in both groups?
• Did the two groups retain a similar baseline prognosis
after the study began?
• Were outcomes measured in the same way in both
groups?
• Was follow-up sufficiently complete?
2. What are the results?
• How strong is the association (e.g., what is the relative
risk or odds ratio)?
• How precise is this association (what are the confidence
intervals of the estimate of effect?)
3. Can I apply these results to my patient?
• Is my patient significantly different from those in the
study?
• Was the study duration of follow-up meaningful for this
clinical context?
• Was the magnitude of the effect large enough to be
important for this patient?
1
Addington J: Cannabis use increases the risk of young people
developing psychotic symptoms, particularly if already
predisposed. Evid Based Ment Health 2005; 8:87
Academic Psychiatry, 32:6, November-December 2008
SRIHARI
Multitasking and the Role of EBM
Evidence-based medicine is a set of tools that offers cli-
nicians an explicit, systematic entry into their third, or sci-
entific, task of evaluating causal inferences relevant to such
everyday clinical acts as comprehending and communicat-
ing prognosis, comparing treatments, and evaluating risk.
Although there are few compelling explanations for the
etiology of most psychiatric disorders, we can say more
about their course, prognosis, and response to treatment.
Much of this is derived from clinical studies of groups of
patients. The data from these studies, however valid and
relevant, must be weighed against individual variability and
the particular values, beliefs, and desires of individual pa-
tients. Clinical expertise operates in this dialectic between
efforts at explanation and understanding (Figure 1).
The distance between the particularities of an individual
case and data derived from studies of groups of cases is
often difficult to traverse and has little to do with EBM
itself. Clinical knowledge rarely emerges from one theo-
retical insight or study but involves a recursive and accu-
mulative process (represented by the curved arrows in Fig-
ure 1). In one direction are models developed from clinical
understanding and tested for their explanatory value. For
example, once strongly held clinical intuitions, such as the
“schizophrenogenic” mother or the value of insulin-coma
therapy (32), have been seriously and properly weakened
by empirical studies that minimized previously hidden bias.
In the other direction, the existing “explanatory” evidence
is limited for many complex clinical situations. We then
need to rely on the components of understanding: empathy
and the judicious choice of interpretive models (whether
neurobiological, behavioral, existential, or psychody-
namic) to supplement the empirical database. Understand-
ing then remains a critical tool for the clinical expert, both
to generate relevant questions for the scientific task, which
can calibrate clinical hunches with the evidence (curved
arrows in Figure 1), and to then engage the patient with
information gleaned from all the tasks (dotted arrow).
Evidence-based medicine, as represented in Figure 1,
can help trainees evaluate clinical studies and respond to
questions about etiology, diagnosis, prognosis, and treat-
ment response. The teaching of EBM empowers trainees
to engage with the challenging, imperfect act of integrating
results from studies testing relatively focused hypotheses
in the complex arena of clinical decision making.
Implications for Training and Practice: On
Becoming Bilingual
I have populated a limited notion of clinical expertise
as consisting of three specific tasks and I have contextu-
http://ap.psychiatryonline.org 467
EBM IN THE EDUCATION OF PSYCHIATRISTS
alized the role of EBM within this notion. While this for-
mulation of the clinical expert defines what skills are to be
acquired, it also suggests a framework within which to im-
plement and evaluate the process of how clinical learning
should occur and where we can look for learning resources.
A concrete curricular plan deserves separate discussion,
but a broad outline is suggested.
For example, a traditional program with supervised ex-
posure to a diversity of clinical cases and didactics in psy-
chotherapy and pharmacology can facilitate empathic and
interpretive skills and background knowledge, but it is in-
adequate training for the scientific task. However, trainees
can be encouraged to formulate focused questions in the
context of routine case presentations. This can initiate the
first step of EBM. Those questions that are judged to be
of importance can then be worked through the subsequent
steps. Trainees and training sites can be evaluated on how
often and adequately this process occurs, in addition to the
traditional supervision of clinical skills. Such a process
implies specific attitudes (e.g., welcoming clinical uncer-
tainty as an opportunity for learning), knowledge (e.g.,
concepts of bias and chance, hierarchies of evidence
sources), and skills (e.g., searching electronic databases in
FIGURE 1. Clinical Expertise
Patient
Appreciating subjective
Empathic Task experience of illness
Generating multiple
Interpretive Task interpretive hypotheses
UNDERSTANDING
Using EBM to alter the
strength of belief in the
original hypothesis and Scientific Task
weigh its applicability
to the patient
EBM⳱evidence-based medicine
468 http://ap.psychiatryonline.org
a time-efficient manner) that are well described in the
EBM literature and can be explicitly assessed.
Why should this notion of clinical expertise be attractive
to those charged with designing residency curricula? First,
the explicit focus on three tasks will enable trainees to be-
come conversant in the distinct languages necessary for
clinical work—the languages of individuals and popula-
tions (33), narrative and science (34), or, as I have de-
scribed them here, Understanding and Explanation. Sec-
ond, training in EBM will empower the trainee to become
a more critical consumer of the scientific literature. The
ubiquity of pharmaceutical advertising heightens the need
for clinicians who can separate the wheat (probabilistic es-
timates of effects) from the chaff (marketing). Third, the
practice of the five steps of EBM can make operational an
approach to uncertainty that has applications beyond the
appraisal of clinical studies. Residents conversant with the
various types of bias (e.g., in patient selection, attrition, or
symptom detection) and the play of chance (i.e., random
error) in their clinical data will be protected from making
inappropriately strong causal attributions from their clini-
cal encounters. Fourth, EBM can serve as a powerful plat-
form for the acquisition of the specialized content and
Using EBM to find
and appraise clinical
Scientific Task studies that test a
specific interpretive
hypothesis
EXPLANATION
Academic Psychiatry, 32:6, November-December 2008

methodological expertise for those trainees who choose to
become clinical researchers. However, I hope to have dem-
onstrated that, far from being an esoteric set of skills of
interest only to future investigators, facility with the prin-
ciples of EBM serves a core function in clinical decision
making.
Clinical encounters with individuals suffering from men-
tal illnesses present uncertainties that belie simple recipes.
Such moments highlight an ever-present tension between
techne and phronesis. If we are to educate residents toward
independent clinical expertise, we would do well to wel-
come this tension as integral to thoughtful clinical work
and an opportunity to practice and develop skills in several
distinct tasks. Our trainees might then be better equipped
to resist premature resolution in favor of explanation or
understanding when both are required.
I am grateful for comments from Andres Martin, Schuyler Hen-
derson, and Stuart Carney. I am also thankful to Dan Bilsker who
provided the template for Figure 1.
References
1. Feinstein AR: Clinical Judgment. Williams & Wilkins, 1967
2. Evidence-Based Medicine Working Group: Evidence-based
medicine. A new approach to teaching the practice of medi-
cine. JAMA 1992; 268:2420–2425
3. Goldner EM, Bilsker D: Evidence-based psychiatry. Can J
Psychiatry 1995; 40:97–101
4. Yager J, Greden J, Abrams M, et al: The institute of medi-
cine’s report on research training in psychiatry residency:
strategies for reform–background, results, and follow up.
Acad Psychiatry 2004; 28:267–274
5. Roberts LW, Coverdale JH, Louie AK: Evidence, methods,
and psychiatric education. Acad Psychiatry 2003; 27:227–228
6. Fenton W, James R, Insel T: Psychiatry residency training, the
physician-scientist, and the future of psychiatry. Acad Psychi-
atry 2004; 28:263–266
7. Straus SE, McAlister FA: Evidence-based medicine: a com-
mentary on common criticisms. CMAJ 2000; 163:837–841
8. Levine R, Fink M: The case against evidence-based principles
in psychiatry. Med Hypotheses 2006; 67:401–410
9. Salzman C: The limited role of expert guidelines in teaching
psychopharmacology. Acad Psychiatry 2005; 29:176–179
10. Gray GE: Concise Guide to Evidence-Based Psychiatry. Ar-
lington, Va, American Psychiatric Publishing, 2004
11. Richardson WS: Teaching evidence-based practice on foot.
ACP J Club 2005; 143:A10–12
12. March JS, Chrisman A, Breland-Noble A, et al: Using and
teaching evidence-based medicine: The Duke University child
and adolescent psychiatry model. Child Adolesc Psychiatr
Clin N Am 2005; 14:273–296, viii-ix
13. Osser DN, Patterson RD, Levitt JJ: Guidelines, algorithms,
Academic Psychiatry, 32:6, November-December 2008
SRIHARI
and evidence-based psychopharmacology training for psychi-
atric residents. Acad Psychiatry 2005; 29:180–186
14. Geddes JR: Evidence-Based Mental Health. London, BMJ,
1998
15. Srihari V, Martin A: Gained in translation: evidence-based
medicine meets pediatric psychopharmacology. Child Adolesc
Psychiatr Clin N Am 2006; 15:263–287
16. Srihari VH: Pulmonary embolism in a patient taking cloza-
pine. BMJ 2008; 336:1499–1501
17. Bilsker D, Goldner EM: Teaching evidence-based practice in
mental health. Evid Based Ment Health 1999; 2:68–69
18. Sackett DL: Evidence-Based Medicine: How to Practice and
Teach EBM. Edinburgh; New York, Churchill Livingstone,
2000
19. Greenhalgh T: Papers that summarise other papers (system-
atic reviews and meta-analyses). BMJ 1997; 315:672–675
20. Green ML: Evidence-based medicine training in graduate
medical education: past, present and future. J Eval Clin Pract
2000; 6:121–138
21. Eraut M: Expert and expertise: meanings and perspectives.
Learning Health Soc Care 2005; 4:173–179
22. Hakkarainen K, Palonen P, Paavola S, et al: Communities of
Networked Expertise: Professional and Educational Perspec-
tives. Amsterdam, Elsevier, 2004
23. Fish FJ, Hamilton M: Fish’s Clinical Psychopathology: Signs
and Symptoms in Psychiatry. Bristol, Wright, 1985
24. Sims A: Symptoms in the Mind: An Introduction to Descrip-
tive Psychopathology. Edinburgh; London, Saunders, 2003
25. Havens LL: Approaches to the Mind: Movement of the Psy-
chiatric Schools from Sects Toward Science. Boston, Little,
Brown, 1973
26. McHugh PR, Slavney PR: The Perspectives of Psychiatry. Bal-
timore, Johns Hopkins University Press, 1998
27. Ghaemi N: The Concepts of Psychiatry: A Pluralistic Ap-
proach to the Mind and Mental Illness. Baltimore, Johns
Hopkins University Press, 2003, pp 299–308
28. Jaspers K: General Psychopathology. Manchester, England;
Chicago, University of Chicago Press, 1963
29. Evidence-Based Medicine Working Group, American Medi-
cal Association, Guyatt G, Rennie D: Users’ Guides to the
Medical Literature: Essentials of Evidence-Based Clinical
Practice. Chicago, American Medical Association Press, 2002
30. Addington J: Cannabis use increases the risk of young people
developing psychotic symptoms, particularly if already predis-
posed. Evid Based Ment Health 2005; 8:87
31. Geddes J: Asking structured and focused clinical questions:
essential first step of evidence-based practice. Evid Based
Ment Health 1999; 2:35–36
32. Hatcher S, Oakley-Browne M: Evidence-Based Mental
Health Care. Edinburgh; New York, Elsevier Churchill Liv-
ingstone, 2005
33. Steiner JF: Talking about treatment: the language of popula-
tions and the language of individuals. Ann Intern Med 1999;
130:618–622
34. Greenhalgh T: Narrative-based medicine: narrative-based
medicine in an evidence-based world. BMJ 1999; 318:323–325
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