What is the Role of the Psychiatrist in the General Hospital? A Blast from the Past

Occasionally I go on these archaeological digs of the medical literature even though I’m as obsessional as anyone about keeping up with the latest data. I’ve mentioned in a previous post Dr. Theodore Stern’s use of the term “supraspecialist” (see blog post “Who’s a Supraspecialist”, January 2, 2011) as a description of a Psychosomatic Medicine practitioner. I think the name “supraspecialist” is unique and Dr. Stern’s creation. Dr. Stern is editor of the journal Psychosomatics and a very active member of the Academy of Psychosomatic Medicine (APM). If you become a member of the APM, you’ll probably be lucky enough to hear him speak at one of the organization’s annual meetings. And by the way, the next one is in beautiful Phoenix, Arizona and the theme is “Innovation and Opportunity in Community Practice Settings”.

At any rate, I think I’ve found an antique reference that presages the supraspecialist label for Psychosomaticists. It can be found in what has arguably been called the first article about consultation psychiatry ever published. The title and introduction are as follows:

The article was published in the 1929 issue of the American Journal of Psychiatry (AJP)[1]. Notice Dr. Henry’s humility; he decided to formulate his experience as a general hospital psychiatric consultant only after he’d seen at least two thousand cases. Non-psychiatric clinicians permitted him to run a clinical study of 300 patients. The occurrence rate of delirium was not different from that of today’s “modern” time—13%. But to
return to the origin of “supraspecialist”, we must consider the next excerpt from Dr. Henry’s paper:

There’s a lot going on in there, but the operative sentence is “The psychiatrist deals with a larger field of medical practice and he must consider all of the facts”. In other words, a subspecialist deals with a fairly circumscribed body of knowledge and skills. A supraspecialist must have a command of a much wider breadth of medical and psychiatric knowledge and the skill set is necessarily broader. And most of us lament the decision made years ago to cut the length of time medical students spend on the clinical rotation in psychiatry in the third year of medical school. Henry evidently shared that concern. Ironically, the role of the psychiatrist in the general hospital was and still is considered vital.

Now to be fair, some things have changed since 1929. Some non-psychiatric resident physicians spend a small portion of their internship year on psychiatric
rotations. At our hospital, first year residents in Neurology and Family Medicine spend a few weeks on our Complexity Intervention Unit (formerly Medical-Psychiatry
Unit, a term I prefer) or on the psychiatry consultation service respectively. We have a psychiatric outpatient clinic of course although it’s a bit difficult for general medicine and surgical staff to refer patients with complex, comorbid psychiatric and medical illness there in a timely manner. I’m afraid the continuity of psychiatric education of non-psychiatric resident physicians is probably haphazard after the first year in most academic medical centers. And frequently, the schedules of psychiatrists simply make it too challenging to attend general medicine grand rounds and similar conferences. This cuts both ways. There are far too few psychiatry grand rounds presentations by speakers invited from medicine and surgery. I’m pretty sure mistakes are made in patient care not just with respect to functional illness but in other neuropsychiatric disorders—delirium among them. So how do we stack up against Henry’s list of improvements which must be done to improve hospital-based patient care in our modern times?

At least in academic medical centers, psychiatric departments are commonplace nowadays. Happily, some of our surgeons are making a good effort to refer some of their patients for pre-surgical psychiatric evaluations…a step in the right direction. Now if I could just persuade them as a group not to use Old Style Beer for alcohol withdrawal treatment. I think we’re very blessed to have a Complexity Intervention Unit to manage the very complex and desperately ill patients who are afflicted with both medical and psychiatric illness. Every medical student now must complete a psychiatry rotation. General medicine and Neurology residents rotate through the service and most enjoy it and learn a great deal. Practical instruction to non-psychiatry resident physicians primarily focuses on recognition and management of the most commonly encountered psychiatric illnesses.

I can’t remember the last time I attended a general medicine grand rounds conference. I barely remember how to get there and I’d better try to find it. I’m supposed to be giving a talk there this summer…on the evaluation and management of delirium.

J Psychiatry, 1929. 86(3): p.