Stimulating experience Clinical expertise and the practice of deep brain stimulation

In everyday clinical practice, no two patients are the same. Expert clinicians are able to translate general knowledge and evidence to a specific patient in their unique context. A crucial part of decision-making, clinical expertise falls outside the scope of established research methods in psychiatry as it involves difficult to verbalize subjective aspects, such as feeling or intuition.
Deep brain stimulation (DBS) is an effective treatment for severe forms of obsessive–compulsive disorder (OCD). Through implanted electrodes in the brain, DBS impacts neurophysiology more directly than any other treatment in psychiatry. This research focuses on the post-surgical phase where clinicians adjust DBS stimulation parameters (active contacts, voltage, frequency etc.), thereby modulating patients’ experience, until symptoms and side-effects are optimally suppressed.
The iterative, evaluative process of DBS optimization offers an interesting case study to explore the role of clinical expertise in psychiatric practice. This dissertation involves an ethnography of the practice of DBS optimization, based on 18 months of participant observation and in-depth interviews with an experienced team of psychiatrists, psychologists, nurses and neurosurgeons in an academic hospital in the Netherlands.
In line with enactive philosophy, clinical expertise is analyzed as a sensitivity to the individual patient’s unique responses to a specific situation as well as to a broader context of established collective patterns of practice. This invites us to understand clinical expertise as neither fully objective nor fully subjective. Despite technological innovations, clinical expertise remains the cornerstone of psychiatry.