Roger G. Kathol

     In December 2001, the Academy of Psychosomatic Medicine received approval from the American Boards of Psychiatry and Neurology to proceed in their application for subspecialty status in "Psychosomatic Medicine". While several steps remain before subspecialty status is granted, this was a major hurtle in the quest by consultation psychiatrists to gain name recognition for the service they provide to medical/surgical patients with psychiatric comorbidity. The importance of this initiative by the Academy is far reaching. It is the initial step needed for funding psychosomatic medicine fellowships. It will allow the development of more consistent and better organized curricula in psychosomatic medicine for psychiatry residents. It identifies a group which can argue the wisdom of adequately reimbursing for psychiatric consultation in the medical setting. Perhaps most importantly, however, is that it gives name recognition to physicians who specialize in the treatment of patients with concurrent medical and psychiatric illness, the first step in fostering growth of the field.

     As most of you know, one of the requirements to receive this approval by the Board was that individuals completing combined residencies but no Psychosomatic Medicine Fellowship be excluded from sitting the subspecialty examination after a grandfathering period. The argument against including those from joint residencies was that it would set precedent since many non-psychiatrist physicians also obtain specialty training in more than one discipline and thus could seek to create their own "subspecialties." While those with combined training in psychiatry and a medical discipline can argue convincingly that the training they receive at least equals and in some ways surpasses the training experiences possible in a Psychosomatic Medicine Fellowship in preparing them to treat patients with comorbid illness, arguing would only waste valuable time. A much more efficient use of our time would be to define and enhance the role that jointly trained individuals have in health care moving forward. Let me explain.

     I personally agree with the decision to allow subspecialty status to proceed for those completing fellowships in Psychosomatic Medicine whether or not those with combined training are included. Allowing this to happen will only augment our advocacy of integrated medical and psychiatric care by increasing the number of physicians entering our area of practice. Those with dual specialties already have two board examinations. Of what value is a third?

     From my point of view, those with combined training are now entering a time of discernment. Of course, they can collaborate with their newly approved Psychosomatic Medicine colleagues in supporting issues which improve the treatment of patients with concurrent medical and psychiatric illness. This will take form in curricula development, advocacy for research funding, collaborative research projects, creation of new and improved models to provide clinical care to those with combined illness, initiatives to augment reimbursement, an many others. This activity, however, is not nearly as important as defining the identity and role of those with joint training in a medical environment which is going to be hungry for psychiatrists interested in working with patients with active medical/surgical and psychiatric illness.

     Speaking as one with combined training, I am convinced that it is time to name ourselves so that our "product line" becomes known and what we do appreciated. For years, I have called myself an "internist-psychiatrist", a name that reflects my training and expertise. Should each of us with combined training do the same-family practitioner (FP)-psychiatrist, neurologist-psychiatrist, pediatric-child psychiatrist? Is there a better way to delineate ourselves?
What we call ourselves is important but is only the first step in making a place for ourselves along side our Psychosomatic Medicine colleagues. Let's face it, while similar in many ways, we are, in fact, different. We can obtain clinical privileges and treat patients in two independent specialties, something that our Psychosomatic Medicine colleagues cannot do. We are members of two independent professional guilds with access to the resources of both. With this training, we possess a unique understanding of the relationship of medical/surgical to psychiatric illness, how the interaction affects outcome, and methods to approach patients with combined illness using the lenses of non-psychiatrist and psychiatrist alike. While subspecialists in Psychosomatic Medicine clearly possess superior knowledge about the evaluation and treatment of patients with comorbid medical and psychiatric illness, how to collaborate with non-psychiatrist physicians, and the unmet needs of patients unfortunate enough to have concurrent illness; their viewpoint perceptibly reflects their orientation in psychiatry.

     My intent here is not to create a shooting match between Psychosomatic Medicine subspecialists and those with combined training for, in fact, there are more similarities than differences between the two. It is rather to encourage those with combined training to learn from our colleagues in Psychosomatic Medicine by taking proactive steps to create an environment in which our special skills can best be recognized, supported, and used.

     This is the 10th anniversary of the Association of Medicine and Psychiatry. Kevin O'Connor, our President, in collaboration with the Association Board are performing a survey to see how the Association can support its membership. I would strongly encourage you to work with the Association in developing survey questions which will allow those with combined training to initiate the steps needed to define themselves and the special role they can play in the future. More professionals are coming from combined residencies than are currently being trained in Psychosomatic Medicine. It is important that we position ourselves to take the kind of roles which allow us to most effectively use our skills.

     I look to the many people with combined training with whom I have had the privilege to work as a source of examples. Many are running integrated treatment programs. Some are doing medical and psychiatric treatment in the emergency setting. Some are supporting medical care in the psychiatric setting (inpatient and outpatient), while others provide psychiatric care in the medical setting, often in subspecialty areas such as oncology, transplant, and pain management. Some have moved to administrative positions, such as Dean for Medical Education or positions on their institutional board. Some are taking positions in the insurance industry, like myself, where there is a growing interest in the coordination of medical/surgical and psychiatric benefits for subscribers (the patients they cover).

     We are fortunate to have a new and energetic Executive Secretary to help us roll out new programs. We have become complacent in our involvement in the Association, relying on it to provide a venue for mutual support and interaction. It is now time to use it to foster growth in our members, delineate our role, and promulgate how we can contribute to better healthcare in the future. I would encourage you to register on the AMP website and participate in the discussions and decision-making processes. I would also encourage you to contact the residency director(s) at the institution in which you did your training and encourage her/him/them to become a member of the Association along with graduates and trainees in their programs. We can only support the interests of those with combined training if the voice of those teaching, being taught, and practicing are a part of the discussion.

     This is obviously a topic of some interest to us all. Please feel free to use the discussion section of the website to share your own views. They are important as we move into the next decade of service to those providing care to patients with medical and psychiatric illness.