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Presidential Address
The Restructuring of the Specialty
Subspecialization—a Major Concern for Present Day and Future Psychiatrists
Specialization and subspecialization have been part of the development
of medicine throughout its history: le développement vertical de la médecine.
Growth in the number of practitioners of a subspecialty occurs in response
to expansion of knowledge base, new technologies, and market forces (social
trends, entitlements).
In the US, Yager and associates predicted that psychiatry would inevitably
“evolve into a discipline with multiple subspecialties and that psychiatry
would increasingly focus on highly circumscribed tertiary spheres of care
built on a strong biopsychosocial knowledge base (22).” They identified
natural areas of subspecialization as population groups, disorders, techniques,
and domains. They argued in favour of a cadre of subspecialists who could
teach residents, but they pointed out that more subspecialization did not
necessarily mean more certificates would or should be granted.
Others have argued that increasing subspecialization will bring about undesirable
fragmentation in the field just as has been decried in internal medicine
and pediatrics (23).
Flaherty states that
It is possible pre-eminence of psychoanalysis in the United States and
in academic departments was responsible for the less pronounced trend toward
subspecialization in psychiatry. Psychoanalytic theory whether classical
or otherwise supports a unified view of human existence and psychiatric
disorders. This view is a developmental one, in which the unfolding of
personality and psychopathology can be understood as part of a universal
process that affects all human beings throughout the life cycle. Diversity
may be seen as variations on a theme; rather than to classify and compartmentalize,
the goal is to understand the uniqueness of the individual in the context
of underlying truths. In contrast, the emphasis on biological and phenomenological
psychiatry in our current era has fostered a segmented approach, which
lends itself to research. The development of specialty clinics is one example
of this. Such clinics allow for intensive investigations into the phenomenology
and responsiveness to interventions of a single disorder. They also serve
a purpose in marketing particular areas of expertise to the public (12).
In the CPA Bulletin of August 2002, the editor-in-chief, Dr AG Awad, titled
his editorial (13): “Subspecialization in Psychiatry: Can We Do it Right?”
In the Mot du president, the President’s Pen, of the same Bulletin, I also
emphasized the major importance of this issue for Canadian psychiatrists,
whether or not they are members of the CPA, and for the Association. I
called for vigilant and sustained monitoring of the process.
The trend for subspecialization is unstoppable:
How do we strike a balance between the need for specialized competence
in certain areas and the preservation of psychiatry as one of the few specialties
that has avoided fragmentation in dealing with the total individual . .
. . A considerable body of knowledge exists in the science and practice
of psychiatry, which has developed over the last few decades, that needs
streamlining toward enhanced competence. That should not only translate
into better services for our patients but should also enhance the depth
of scientific understanding in these areas (13).
However, we should be aware of the profound implications, as it will change
the postgraduate education template, and the repercussions on the clinical
practice of psychiatry, on the psychiatric workforce, on remuneration,
and on the structure of the CPA.
I’m happy to report that CPA has a solid, very qualified working group
looking at this particular issue, cochaired by Dr John Leverette and Dr
Emmanuel Persad.
The CPA Working Group on a National Strategy for Postgraduate Education
in Psychiatry: an update from the working group subcommittee on the Primary
Specialty Model in a memorandum dated October 1, 2002, states that
While moving expediently to study the model and seek feedback from stakeholders,
the subcommittee’s position has been and continues to be that this is a
reflective, consultative process that is not driven by a final timeline.
There is also no intent by the Royal College to impose this model on specialties
and from the subcommittee’s standpoint, the applicability of the current
model or possible variations of it to psychiatry can only be determined
by a broad consensus. The subcommittee has sought consultation and deliberated
extensively on the strengths and weakness of the Primary Specialty Model
as currently applied in Internal Medicine and its related subspecialties.
A key principle in its review is that core training must provide sufficient
knowledge and skill for a graduate in a primary specialty to function as
a psychiatric generalist. The model seems to lack the flexibility to accomplish
this within 5 years of training as well as preserving the desired goal
of most residents to become sophisticated generalists. Additional undesirable
implications of the model for psychiatry include the premature streaming
of residents during training, the burden of additional examinations, and
the impact on small and medium sized programs. Having reached these conclusions,
the subcommittee will now continue its work by delineating the core competencies
required in residency and by developing a made in psychiatry Primary Specialty
Model that will preserve and support the training of the sophisticated
generalist while providing primary specialty recognition. Broad consultation
and consensus will be sought before any model is submitted for review to
the Royal College’s Committees on Specialties and Evaluations (14).
Le recrutement en psychiatrie : Recruitment in Psychiatry
Psychiatrists in clinical practice know that there is a bug in the relief
of troops. A most interesting article by doctor Eugenia Zikos, a resident
in psychiatry at McGill, was published in the February 2002 issue of the
Bulletin: “Recruitment in Psychiatry: ‘Shrinking’ interest?” Doctor Zikos
dealt with the shrinking interest of medical students to pursue a career
in psychiatry. She quotes several surveys that dealt with the possible
reasons for such a decline interest.
In the editorial of that Bulletin, the editor-in-chief wrote, and I quote:
Obviously there are several reasons. One of the reasons, revealed in surveys,
which is certainly disappointing for me, as well as for many of you, is
that psychiatry medical students perceive psychiatry as an ‘unscientific
specialty.’ This lingering unjustified perception runs contrary to the
significant advances over the past 50 years that placed psychiatry as a
credible scientific field, based on a credible body of knowledge. How does
one reconcile such prevailing negative perceptions of psychiatry among
medical students and I dare say, among many of our specialist colleagues?
(15)
And he goes on to wonder whether
one of the reasons is that some of the recent modern scientific knowledge-base
in psychiatry has not permeated enough in training curricula, nor has it
been grounded well into the philosophy of the training of new psychiatrists
(15).
Over the past few years, we have heard a lot of talk about the skills required
for the psychiatrist in the 21st century, but we have not yet seen major
shifts or changes in the training of psychiatrists.
Current models of clinical training will need to be changed to respond
to the new scientific and economic realities and vice versa. Psychiatrists
in clinical practice must be aware that the long-term vitality of the field
depends on science and the translation and relation of service to clinical
care and also on the recruitment, as well as retention, of most able teachers
and researchers in academic medical centers (24).
We can expect the university departments, “the academics,” to play their
role and be mentors to entice medical students to psychiatry.
But the clinicians must also be recruiting agents. We will have to keep
abreast of knowledge and skills in our field. Then, it will spread to colleagues
from other disciplines and to students. To attain this, psychiatrists must
actively participate and be learners. New methods will need to be developed
and applied to sustain the competencies of psychiatrists in clinical practice.
Organized psychiatry will have to support continuing professional development
most actively.
Also, we have to live with the fact that the teaching of psychiatry is
anomalous. In contrast to internal medicine, surgery, or pediatrics, psychiatry
does not, indeed cannot at this time, emerge straightforwardly from the
course of study in physics, chemistry, and biology that medical students
have followed since college.
Psychiatrists in clinical practice know and need to acknowledge that marketing
factors and advertising campaigns can shape descriptions of symptoms and
understanding of treatments:
Current direct-to-consumer advertisements catalyse a host of clinical situations
that seem antithetical to psychiatric principles that hold to meanings
within the therapeutic dialogue as sacrosanct. Yet only by letting advertisements
into the Examination Room, so to speak, can clinicians reclaim expertise
in the desires and expectations so well identified by the advertisements
themselves. In the process, clinicians can begin to translate general discussions
of the anxieties upon which all pharmaceutical advertisements depend, into
the unique meanings of these drugs for each individual patient (16).
Psychiatrists live also with the stigma attached to mental disorders. There
is stigma in the medical profession. A great way to defeat the stigma of
a disease is to have a cure. Clinical practitioners need to be backed by
solid researchers.
The Need for New Models of Service Delivery
Psychiatrists not only know but experience the rising demand for psychiatric
services and should be aware that new models of service delivery will have
to be designed.
Psychiatrists must be aware that the public, patients, and families will
have to be involved in the shaping of services.
Psychiatrists will be able to meet this challenge by collaborating with
our many colleagues in medicine and other professions and sectors. Collaboration
with other providers is both essential and desirable and often occurs in
the context of multidisciplinary teams.
Interdisciplinary work must not lead to deskilling and loss of our professional
identity.
Psychiatrists must champion the maintenance of standards and accountability
while promoting collaboration with other mental health professionals.
Looking Ahead
The physicist Neils Bohr commented that “prediction is difficult, especially
about the future.”
Few psychiatrists prognosticating in the 1940s would have anticipated the
profound impact of the 1952 clinical trial of chlorpromazine on treatment
of patients with severe and persistent mental disorders on the development
of psychopharmacology and on the conceptualization of psychiatry.
Frank and Kupfer in their article “Peeking Through the Door of 21st Century”
(17) pose 6 questions for our field:
How does life experience alter gene expression in vulnerable individuals? What are the neurobiological effects of psychotherapy? How does trauma lead to such a wide and complex range of symptoms? Can we develop adverse effect–free pharmacotherapies? What is the connection between various physical illnesses and mood and anxiety regulation? How does the aging process affect disorder expression and treatment?
To these, Goldbloom and Garfinkel add the importance of understanding protective
factors in the evolution of disease in vulnerable individuals (7).
WM Cowan and Eric Kandel, a psychiatrist and Nobel Prize laureate, state
that
given that by most estimates more than half of the 40 000 to 50 000 genes
in the human genome are expressed either exclusively on preferentially
in the brain, we may confidently anticipate that when the entire sequence
of the human genome becomes available and has been appropriately annotated—now
anticipated to occur within the next 2 or 3 years—progress, not only in
neuroscience, but in neurology and psychiatry, will proceed at an unprecedented
pace (18).
In the afterword of the book Psychiatry in the New Millennium, Sidney Weissman
comments that “Psychiatry in 2000 will be neither molecular biology nor
psychoanalysis, nor social psychiatry, yet it will be informed by all three
of these disciplines, as well as by others” (19).
As psychiatrists use different sources of information or data to understand
mind–brain, they realize that they need strikingly different abilities
to interpret the new-found sources of knowledge. Reductionist models ignore
input from other sciences that study human thoughts, moods, and behaviours.
Many nod favourably to the importance of the biopsychosocial model, but
in fact, many or most ignore it for the simple reason that we as psychiatrists
are not effectively trained to master the subdisciplines required.
Residency programs must be redesigned, and psychiatrists must pursue their
continuing professional development, to ensure such competence in all areas
that inform our field.
Be it now or in the future, psychiatrists have and will continue to have
duties far beyond those of a provider. Be it now or in the future, psychiatrists
need and will continue to need to be professionals. Medical and psychiatric
professionalism includes both the relationship between a physician and
a patient and a social contract between physicians and society. The 3 major
features of medical professionalism—the ethic of service, clinical autonomy,
and self-regulation—benefit patients and society (20). Medical professionalism
is being challenged from within and without, be it resource restraints,
bureaucratic challenges, unprofessional conduct, commercialism, consumerism,
or health care delivery fragmentation. Individual psychiatrists should
protect and enhance professionalism in psychiatry by reflecting the values
of psychiatry in their practice and by contributing to the efforts of organized
psychiatry and medicine to maintain and enhance the ethic of service, clinical
autonomy, and self-regulation.
Psychiatrists know that they are professionals dedicated to providing service
and advocacy for their patients, that they have specialized knowledge,
that they set standards and maintain them internally, that they keep their
eye on long-term goals, and that they help address society’s needs.
Finally, the history of psychiatric therapy shows 3 major trends to treatment:
biological therapy, psychological therapy (psychotherapy), and environmental
engineering (sociotherapy).
The 3 therapeutic approaches in question are not elements that dovetail
together. Rather, they establish between themselves relations of an entirely
other sort; namely, dialectic ones. It is necessary to recognize the dialectic
nature of psychiatric therapy and its history.
When psychiatrists see the tensions generated through this dialectic as
the motor of progress, psychiatrists help to stretch the envelope of their
resources and abilities and institute a form of psychiatric therapy that
sees the patient as a living, biological, psychological, and social whole.
Our vacillations and varying forms of treatment then cease to be incoherent,
to the degree that we realize that they are evidence of a dialectic movement,
and to the degree that our vacillations and varying, now rescued from the
world of chance, have themselves become and object of science.
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