Two approaches to improving mental health care: positivist/quantitative versus skill-based/qualitative.

The quality improvement model currently used in medicine and mental health was adopted from industry, where it developed out of early 20th-century efforts to apply a positivist/quantitative agenda to improving manufacturing. This article questions the application of this model to mental health care. It argues that (1) developing "operational definitions" for something as value-laden as "quality" risks conflating two realms, what we measure with what we value; (2) when measurements that are tied to individuals are aggregated to establish benchmarks and goals, unwarranted mathematical assumptions are made; (3) choosing clinical outcomes is problematic; (4) there is little relationship between process measures and clinical outcomes; and (5) since changes in quality indices do not relate to improved clinical care, management's reliance on such indices provides an illusory sense of control.

Clinical expertise and the limits of explicit knowledge.

This article questions the view that medical decision-making can be reduced to a series of explicit rules, adherence to which will necessarily improve outcomes. Instead, it attempts to rehabilitate the concepts of clinical expertise and clinical experience, arguing that medicine, like other areas of expertise, depends on forms of implicit knowledge that can only be acquired through years of experience. Recent research on "fast and frugal" heuristics in medical decision-making suggest that statistical techniques are not necessarily superior to clinician judgment.

Quantifying the contribution of VA service-connected disability pensions to the "check effect".

Objective: The study attempted to quantify the effect of receiving a disability pension check at the beginning of the month on the timing of substance-related hospitalizations in Department of Veterans Affairs (VA) facilities.

Methods: All substance-related hospitalizations during fiscal year 2005 were identified in the VA National Psychosis Registry (13,402 hospitalizations among 8,813 individuals) and in a random sample of VA patients without serious mental illness (689 hospitalizations among 508 individuals). Multivariable logistic regression examined the impact of pension check receipt on timing of hospitalizations while controlling for other predictors of substance-related hospitalizations.