Gunslingers and Chessmasters

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat”—Sun Tzu.

In 2003 the American Board of Medical Specialties approved the subspecialty status of Psychiatry now known as Psychosomatic Medicine. Long before that, the field was known as Consultation-Liaison Psychiatry. In 2005, the first certification examination was offered by the American Board of Psychiatry and Neurology. This important point in the history of psychiatry began many decades ago, probably in the early 19th century, when the word “psychosomatic” was first used by Johann Christian Heinroth when discussing insomnia.

Psychosomatic Medicine began as the study of psychophysiology which in some quarters led to a reductionistic theory of psychogenic causation of disease. However, the evolution of a broader conceptualization of the discipline as the study of mind and body interactions in patients who are ill and the creation of effective treatments for them probably was a parallel development. This was called Consultation-Liaison Psychiatry and it was considered the practical application of the principles and discoveries of Psychosomatic Medicine. Two major organizations grew up in the early and middle parts of the 20th century that seemed to formalize the distinction (and possibly the eventual separation) between the two ideas: the American Psychosomatic Society (APS) and the Academy of Psychosomatic Medicine (APM). The name of the subspecialty finally approved in 2003 was largely because of its historic roots in the origin of the interaction of the mind and body paradigm.

The impression that the field was dichotomized into research and practical application was noted by members of both organizations. At a symposium at the APM annual meeting in Tucson, AZ in 2006, one speaker remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

It is ironic how organizations that are both devoted to teaching physicians how to think both/and instead of either/or about medical and psychiatric problems could have become so dichotomized themselves.

The motive for writing this post evokes a few quotations about psychiatry in general hospitals:

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods” [1].

“All staff conferences in general hospitals should be attended by the psychiatrist so that there might be    a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems”[1].

“The time should not be too long delayed when psychiatrists are required on all     our medical and surgical wards and in all our general and surgical clinics” [2].

The first two quotes, modern as they sound, are from 1929 in one of the first papers ever published about Consultation Psychiatry, by George W. Henry, A.B., M.D. The third is from 1936 by Helen Flanders Dunbar, M.D., in an article about the substantial role psychological factors play in the etiology and course of cardiovascular diseases, diabetes, and fractures in 600 patients. Although few hospital organizations actually practice what these physicians recommended, the recurring theme is the need to improve outcomes, processes, and education in health care by integrating medical and psychiatric delivery care systems. Further, Roger Kathol, M.D., has written persuasively of the need for a sea change in the way our health care delivery and insurance systems operate in order to improve the quality of health care in this country so that it compares better with that of other nations [3]. Change is sometimes slow in coming.

Some of the barriers to change, with respect to just one specific area, organ transplant, for example, by Wolcott (paraphrased and italics mine) [4]:

  • Limited number of psychiatrists and other mental health care providers with sufficient knowledge, skills, interest, and time (manpower)
  • Smaller transplant programs cannot support a full organ transplant psychiatry program (money)
  • Variable emphasis and priority placed on psychiatric outcomes (and by extension, their value) by organ transplant programs themselves (motivation)

“Manpower, money, and motivation” will be a familiar echo to some psychiatrists who still believe it is worthwhile to make a distinction between a consultation service and a consultation-liaison alliance with the rest of medicine and surgery. A consultation service is a rescue squad; like a volunteer fire brigade, it “puts out the blaze and then returns home”. A liaison service “sets up fire prevention programs and educates the citizenry about fireproofing” [5].

While it is worthwhile to make the distinction, it is still important to prize both. The need for research in Psychosomatic Medicine is critical and gives the field vitality. Those who conduct research are the chess masters. However, the patients don’t always read the medical literature, and don’t always fit the predictions of chess masters. Out on the wards, there is a need for consultants to intuitively create responses to novelty that cannot always be found in journals or books. These are the gunslingers. They know that the clinical world outside of what the Institutional Review Board allows is “inherently unpredictable and messy and nonlinear” [6]. Change is always coming.

In this field there are chess masters and gunslingers. Both are needed. One needs to be a gunslinger to react quickly and effectively on the wards and in the emergency room during crises. One  also needs to be a chess master after the smoke has cleared, to reflect on what one did, how it was done—and analyze why it was done and whether that was in accord with the best medical evidence.

This post is for the gunslinger—who relies on the chess master. It is also for the chess master—who needs to be a gunslinger.

References:

1.         Henry, G.W., SOME MODERN ASPECTS OF PSYCHIATRY IN GENERAL HOSPITAL PRACTICE. Am J Psychiatry, 1929. 86(3): p. 481-499.

2.         Dunbar, H.F., T.P. Wolfe, and J.M. Rioch, PSYCHIATRIC ASPECTS OF MEDICAL PROBLEMS: The Psychic Component of the Disease Process (Including Convalescence), in Cardiac, Diabetic, and Fracture Patients. Am J Psychiatry, 1936. 93(3): p. 649-679.

3.         Kathol, R.G. and S. Gatteau, Healing body and mind : a critical issue for health care reform. Praeger series in health psychology. 2007, Westport, Conn.: Praeger Publishers. xviii, 190 p.

4.         Wolcott, D.L., Organ transplant psychiatry: psychiatry’s role in the second gift of life. Psychosomatics, 1990. 31(1): p. 91-97.

5.         Strain, J.J., M.D., Liaison Psychiatry, in Textbook of Consultation-Liaison Psychiatry, J.R. Rundell, M.D., and M.G. Wise, M.D., Editors. 1996, American Psychiatric Press, Inc.: Washington, D.C. p. 38-51.

6.         Gladwell, M., Blink : the power of thinking without thinking. 1st ed. 2005, New York: Little, Brown and Co. viii, 277 p.

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