Neuroscience Medicine Consultants Replace Psychosomaticists?

NeuroscienceMedicine (2)My former teacher, Dr. William R. Yates, has made a bold proposal to form a new specialty, Neuroscience Medicine, by combining Psychiatry and Neurology, which he has outlined succinctly:

I’m ambivalent about it because of what would have to be done. It would be a lot of work (putting it mildly) to get this through the American Board of Medical Specialties. I’ve mentioned this in a previous post. Again, the American Psychiatric Association might decry the proposal as further balkanization of psychiatry. On the other hand, Dr. Larry Faulkner, MD, President and CEO of the American Board of Psychiatry and Neurology, might welcome the change. Think of the cash flowing in from diplomates for Maintenance of Certification (MOC) “products” including recertification exams!

I’ve not yet heard from one of my colleagues in Neurology whose opinion I asked for about Bill’s proposal. I get the sense many residents in both Neurology and Psychiatry probably would rather than fight than switch at this point in their careers.

Dr. Jim Amos with Dr. Don Lipsitt's book Foundations of CL Psychiatry - CopyDr. Don Lipsitt, author of “Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization,” which I’ve just begun reading, said the term “Neuroscience Medicine” didn’t “do it” for him as a replacement for “Psychosomatic Medicine.” My little poll shows that “Consultation-Liaison Psychiatry” was the most popular name. You can still vote if you like.

 

 

 

I noticed that the word “psychosomaticist” turns up in Don’s book, which surprised me a little. I thought I made that up just for my blog. He mentions it in the first section “Seeds and Roots.” As Bill points out, the word psychosomatic may be a holdover from the days of Freud and psychoanalysis–but the roots are long and strong and it might be going too far to say that “psychoanalysis is dead.” However, in the era of what might be called biological reductionism, this stance might attract more than a few medical students to Neuroscience Medicine.

It’s fair to point out that even in Bill’s proposal, psychology has a place as a supporting specialty. How could it not? And it’s not a novel proposal. In fact, as I’ve already mentioned in a previous post, there is a combined Neurology and Psychiatry training program at the NYU Langone Medical Center. I sent the Program Director, Siddhartha Nadkarni, MD, an email message asking for an opinion about the issue.

IMG_0965 - CopyDoing what I do every day as a psychiatric consultant in the general hospital is analogous to what a smokejumper (fireman) does. I put out fires. I don’t need hardly any neuroscience training for that. In fact, most of the time all I need is a chair–to sit down and listen to patients and families.

Of course, I’m aware that empathy, while essential, is not sufficient to make a difference in the world of medicine. My colleague, Dr. George Dawson, says psychiatry should be more like opthalmology. I wish we could make it so.

It makes me wonder. If a Neuroscience Medicine specialty is approved, what will happen to all of the general psychiatrists and neurologists…and the psychosomaticists? And if the new discipline is to “reduce the burden of brain disorder around the world,” how will it do that?

Bill is making a great effort to move medicine forward. Don is also making a great effort to give us perspective on where medicine has been.

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We need both. Otherwise we risk sitting around dreaming about the past.

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Comments

  1. The poll is a prime example of what is wrong with psychiatry. It attempts to use wording to appear scientific while standing in the way of real scientific progress. I’d much rather have neuroscience reduce my symptoms to actual biological underpinnings than have psychiatry reduce me to a concocted DSM label. Neuroscience has the potential to provide for treatments that directly target symptoms at their foundation instead of merely analyzing apparent symptom manifestations and applying hit or miss techniques based on (overly) generalized ideas about behavior.

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  2. One other thought on this issue. What we call ourselves should be sensitive to the referring physician and the patients. If a patient with an MI becomes depressed, which narrative is easier (more acceptable) for the referring physician and the patient?

    1.”I want you to see one of our physicians specializing in neuroscience medicine”
    2. “I want you to see a psychiatrist” or “I want you to see a consultation-liaison psychiatrist”
    3. “I want you to see a psychosomaticist”

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    • You make a very good point, highlighting the problem many of us have with “psychosomaticist.” I’m pretty sure that the name will probably stick, though. The American Psychosomatic Society went through a name change struggle a few years ago that is similar to what the Academy of Psychosomatic Medicine is going through currently with respect to the Psychosomatic Medicine name.

      Incidentally, I just got a message from one of the medical student’s rotating on my service thta the Combined Psychiatry and Neurology residency at Brown might no longer be active, https://www.brown.edu/academics/medical/about/departments/neurology/subspeciality-programs/neuropsychiatry/neuropsychiatry-combined-residency

      On the other hand, he plans to co-present a CPCP on the neuropsychiatric care of poststroke patients, so there will definitely be a neuroscience theme!

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  3. Thanks so much Jim for highlighting my post and stimulating discussion.

    I would not be worried too much about changing the board and subspecialty certification leaders on this issue. They have vested self interest in maintaining legacy semantics and organization.

    I would just move directly to an academic departmental model of Neuroscience Medicine maintaining legacy training structures for awhile.

    I would predict this integrated and coordinated model would stimulate three things:
    1.) Improvement in patient care and outcomes
    2.) Increased research funding and research advances
    3.) Increased recruitment of the most talented physicians and basic neuroscientists

    These three things would be the drivers. The boards and specialty leaders would eventually need to be the ones who see this improvement and adapt.

    Bill

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    • I appreciate these thoughts. In the last couple of years, neurology residents have been rotating through the psychiatry consultation service. I get the impression they like the experience and get a lot out of it. I enjoy working with them. However, I also know that neurologists and psychiatrists may have different ideas about certain neuropsychiatric conditions, like conversion disorder.

      It’s clear that some academic departments have bridged those conceptual gaps and work together well enough to produce successful combined psychiatry and neurology residencies, mentioned by Siddhu (see below). I found a pretty good first person description by a medical student in one such program, see link http://forums.studentdoctor.net/threads/combined-neurology-psychiatry.847157/

      I hope boards don’t touch these programs with Maintenance of Certification (MOC). Most of us have had enough of it. See the Psychiatric Times May 2016 article “11 Reasons Physicians Hate Maintenance of Certification (MOC) by Steph Weber, http://imaging.ubmmedica.com/all/editorial/physicianspractice/pdfs/11-Reasons-Docs-Hate-MOC.pdf

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  4. Jim,

    I think the idea is dead in the water.

    Many psychiatrists view anything “neuro” as something you study for the boards – before settling in for a long career of not thinking about it again. For many it is a self fulfilling prophecy.

    And for many the last thing they would want is to jump through more ABPN hoops.

    George

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    • I tend to agree. However, Dr. Siddhartha S. Nadkarni, MD at NYU got back to me today and said:

      “I think that is a great idea. Not sure folks are ready for it. Definitely not ACGME accredited in terms of training, but we do have (and there are a few other) double board neurology and psychiatry residency programs in the country, which is essentially that. Also, there are some neuropsychiatry fellowships.
      —Siddhu.”

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