Assessment of drunk patients

the clinic. Needless to say, this attitude had a negative effect on the patients who felt despised for taking an overdose. Another difficulty I faced was inappro priate referrals by the psychiatric trainees. The clinic was overwhelmed by referrals of drinking problems, marital difficulties and social and housing problems. This problem was solved by allocating two induction sessions for the newcomers to psychiatry to explain the function of the clinic.

wish to challenge certain widespread assumptions concerning the assessment of inebriated patients. Policy, either implicit or possibly enshrined in some document, is generally to exclude patients who at tend for assessment whilst drunk. Often in condes cending terms, they are asked to remove themselves (or be removed) and are invited in an equally condescending fashion to re-present when sober.
This clearly is both economic and safe since so many alcohol dependent patients cannot summon the courage to seek help during intervals of sobriety. Alcoholics Anonymous recognises this problem and welcomes the moderately inebriated so long as their behaviour is tolerable. Similarly, so long as I do not consider that the patient's behaviour is unreason able, I find it often valuable to conduct the interview in the state in which the patient has been able to present him/herself. (I do not permit smoking.) Contrary to accepted wisdom, caring inter ventions by the clinician are generally remembered by the mildly inebriated patient, and these greatly increase the likelihood of reattendance when sober. The disinhibition afforded by alcohol may render an otherwise prickly patient capable of providing an honest account of every aspect of his life, not least a more accurate drinking history.
I do take a certain risk, and sensible precautions are vital: I do not wish to be assaulted, my consulting room smashed up, or have my carpet vomited upon. However, In vino veritas, and surely veritas is the sine qua non of any assessment.

JOHNSTEVENS Si Francis Hospital Hay wards Heath, West Sussex
Psychiatrists' use of investigations DEARSIRS I read with interest Dr Anthony White's paper on psychiatrist's use of investigations (Psychiatric Bulletin, October 1988, 12, 430-433). Dr White's comments on his findings fail to mention some rather obvious possible explanations for the results and make some assumptions that should be challenged. There appears to be an assumption that fewer investi gations equate with better practice, and that the practices followed by consultants are inevitably bet ter than those of their junior colleagues. I would like to challenge those assumptions by proposing that the reason the number of investigations thought appro priate for a particular case reaches a peak at registrar level, and thereafter declines to consultant level, is that registrars have their heads crammed full of facts and figures in preparation for their examinations, and that this mass of knowledge eventually decays to consultant level. It is with the decay of this knowl edge that the unusual or rare case stands out more noticeably, and the availability heuristic comes to influence the process of making a diagnosis. I would propose that far from producing more investigations striving to make predictions come true, this heuristic produces fewer investigations which might refute the prediction. Survey any group of juniors and they will tell you all too readily of how frustrated they become when faced with the operation of the anchoring and adjustment heuristic which prevents their consultant relinquishing a diagnosis based on the availability heuristic, despite the refutatory evidence produced (perhaps from further investigations).
Even for the best clinician, who makes judgements free of heuristics and bias, the nature of a consult ant's work is so different from that of a junior that one might expect differences in practice. A consultant can usually work with the assumption that simple, routine, or screening investigations have been done by the juniors (if not, why not?). It is in the nature of a consultant's work to be concerned with the few incis ive investigations while leaving the commonplace in the hands of their juniors. I would have been inter ested to have seen a breakdown of Dr White's results by type of investigation.
Although I do not doubt the therapeutic effect of investigations for the investigator, this does not auto matically negate their diagnostic value, or mean that their use is a problem. In order to make economic savings one would have to reduce considerably the numbers of a particular investigation ordered. Almost certainly that would result in an increase in the cost per investigation. Many investigations are carried out in bulk, and are a necessary and appropri ate part of the care of patients in other specialities. The cost per item is thus quite low, and is unlikely to be affected by a small reduction in work for psy chiatry. What price should we put on the detection of those cases of "Wilson's disease or parasagittal meningioma that the textbooks and lectures would have us believe languishes on every back ward"?

S. J. ADAMS Brunswick House Glossop Road, Sheffield
Dr White replies DEARSIR The hard results in my paper demonstrate some out come research. The process which led to this outcome was the decision-making behaviour of clinician psy chiatrists. This process cannot be demonstrated by any method presently available to us and will always be open to conjecture. I am delighted to engender discussion, either through the Psychiatric Bulletin or in person, about the nature of the process.
The phenomena that Dr Adams and I have both addressed are in the realm of judgement and decision-making (JDM ) theory, the understanding of the processes ofjudgement and choice. Approaches to 89 understanding decision behaviour originated two centuries ago with Bernoulli's (1713) ideas in econ omics and Bayes' (1763) theorem for games theory.
Further contribution came from utilitarian philos ophy. The early part of the 20th century saw attempts to produce normative models of JDM theory. Numerous disciplines, statistics, economics, man agement, philosophy, social policies and law, as well as psychology, have found value in these models of JDM theory for understanding and improving the accuracy of their work. Medicine has been strangely absent from that list.
The evidence, from innumerable other sources as well as myself, has shown that man is clearly not the rational being he would like to believe (Polya, 1941;Kahnemann, Slovic & Tversky, 1982). As a result, recent years have seen a change in emphasis from normative theories of perfect JDM towards descrip tive theories that attempt to understand the anom alies and aberrations found in decision behaviour wherever it takes place (Kahnemann, Slovic & Tversky, 1982;Kahnemann & Tversky, 1979;Slovic, Fischhoff & Lichcnstein, 1977). Heuristics have proved one of the most prominent and successful contributions. The challenge facing this intriguing field is to bridge the gap between the theoretical core of JDM and the various practical applications.
The way that Dr Adams and I can attribute such simple differences in outcome to such wide differ ences in process suggests that the time is ripe for application of decision theory in medicine.
ANTHONY WHITE Glenside Hospital S tapieton, Bristol