General hospital psychiatry: a new sub-specialty?
Authors: Rodolfo Fahrer
Journal: World Psychiatry (2003)

Psychiatry has been definitely incorporated and integrated into the rest of medicine and into the general hospital as a medical specialty, following the trend towards community psychiatry and deinstitutionalization, which came hand in hand with the emergence of new therapies and the reduction of stigma, promoting integration with the family and a more effective psychosocial rehabilitation. General hospital psychiatry covers a wide range of areas, from consultationliaison psychiatry to the management of acute psychiatric patients in the general hospital setting.

These developments brought about a very important change in the role and in the identity of the general hospital psychiatrist. The new responsibilities implied the necessary training for an efficient assistance of patients, research activities and teaching functions in all the areas of psychiatry.

The American Board of Psychiatry and Neurology has recommended a sub-specialty status for consultationliaison psychiatry, under the denomination of 'psychosomatic medicine'. If this is approved, the first certificate would probably be awarded in 2005. Psychosomatic medicine would then become the seventh sub-specialty within psychiatry.

The subject of sub-specialization is a very controversial one. It has its supporters and those who think otherwise. According to Yager (1), subspecialization is desirable and makes the field stronger. Accredited sub-specialty programs increase focus, scholarship and research, enhance the presence and the influence of the specialist in academic centers, and may influence positive decisions concerning managed care decisions.

On the other hand, McKegney et al (2) point out that consultation-liaison psychiatry should be considered a 'supra-specialty', because it is significantly involved in many of the 'subspecialty' areas throughout psychiatry. While sub-specialization is important and accreditation of consultation- liaison psychiatrists will result in increased focus, scholarship and research, we should consider whether renaming it 'psychosomatic medicine' is the most appropriate thing to do. On the one hand, psychosomatic medicine refers to the integrated focus on mind/soul and body, that we know as the holistic conception of medicine, or the 'the biopsychosocial approach'. On the other, the term psychosomatic medicine is linked to the concept of psychosomatic diseases, which is no longer in vogue.

There is no doubt that the new paradigm for general hospital psychiatry demands a training beyond that of the consultation-liaison psychiatrist, because the psychiatric physician working in the general hospital has to assist not only psychosomatic patients but also patients with all kind of psychiatric and cerebral/organic disorders. Another element to be taken into consideration is the aging of the population, with the increase in agerelated neuropsychiatric morbidity associated with dementia, stroke, and Parkinsons disease (3).

In 1978, Denis Hill said that the psychiatrist should be a physician, a scientist, a psychotherapist and a leader. Today, these attributes are not sufficient. The general hospital psychiatrist of the 21st century must be a physician, a scientist, a psychotherapist, a leader, a teacher, a capable and skilful team worker (4). To this we must add knowledge of forensic medicine, economics and administrative aspects of managed care.