Last fall the APM and AMP submitted an application for subspecialization of "Psychiatry in the Medically Ill" (C-L) to the APA Assembly and the Committee on Medical Education. This submission included wording which allowed grandfathering of psychiatrists who had completed combined residencies in psychiatry and internal medicine, family practice, or pediatrics. Such individuals would be allowed to take the subspecialty examination for five years after it was introduced. After the grandfathering period, both those who completed Fellowships in Psychiatry in the Medically Ill and those who completed combined residencies would be eligible to sit future examinations.

After initial rejection by the Council on Medical Education, it was possible to bypass this Council and submit the application to the Board of Trustees (BOT) of the APA for review and approval prior to its submission to the American Board of Psychiatry and Neurology. The review by the BOT identified two areas in which they desired substantive change. First, they wished the name of the discipline to be changed to "Psychosomatics" from "Psychiatry in the Medically Ill". Their reasoning for this change was that they felt that Psychiatry in the Medically Ill implied that general psychiatry was not "medical". While they did not wish to return to the name "Consultation-Liaison" since it described a location of practice, they thought that "Psychosomatics" best described the area of clinical activity in which we were involved.

The second change suggested by the BOT was to exclude those who have only completed combined training from taking the examination after the grandfathering period. Their reluctance to include physicians with combined training stems from the fact that the American Board of Medical Specialties advised them that to do so would surely cause rejection of the application, if not at the ABPN level, then at the ABMS level. The reason was that to do so would set an unwanted precedent for other medical disciplines in which completion of more than one Board is accomplished. They do not want numerous subspecialties created just because physicians chose to complete training in more than one specialty area.

In response to these suggestions, Kostas Lyketsos revised the application to comply with the BOT's wishes. Before it was resubmitted, the changes were opened to discussion on the AMP listserve. Most who entered the discussion were not particularly happy about the name change but were willing to accept "Psychosomatics" if it meant subspecialty status would become more likely.

The second issue was more contentious. With few exceptions, those with joint training and those in combined residency programs felt that it was shortsighted to exclude psychiatrists who had completed board requirements in a primary care discipline from sitting the subspecialty examination. In essence, a critical component of those involved in the care of patients with comorbid medical and psychiatric illness was being "sacrificed" so that consultation psychiatrists could receive subspecialty status. While this argument is legitimate, it does not address the fact that unless this part of the application was altered, it would not even have a hearing with the ABPN/ABMS.

Neither of these BOT suggestions were well received by those involved in preparing and submitting the application for subspecialty status. It was necessary, however, to make concessions for the application to proceed. The bottom line is that the overriding issue is for Psychiatry in the Medically Ill, C-L Psychiatry, Psychosomatic Psychiatry, or whatever it is called to obtain subspecialty status for purposes of billing, fellowship accreditation and financial support, and ultimately improved patient care. While doing this independent of the recognized boarding organizations was a consideration, it would be both expensive and less effective in achieving the ultimate goal of C-L as a discipline. For this reason, the subspecialty application committee, has revised and submitted the application in accordance with the wishes of the BOT.

We who have completed combined training programs can respond to this action by the APM and its subcommittee on subspecialization in two ways. We can feel that we have been excluded from an important professional accreditation procedure and abandoned by the APM or we can recognize the value that we bring to the care of patients with comorbid medical and psychiatric illness and foster our own professional identity independent, but coordinated with, the agenda of consultation psychiatrists. We remain in the business of caring for patients with concurrent illness. The first response is self-defeating and non-productive. The second opens opportunities for those with combined training which may not even be available as a part of the new subspecialty. Also it may be entirely possible for individual dual residency programs to modify their rotations and curriculum content to satisfy the requirements to sit the "psychosomatics" exam.

Those with combined training already have board eligibility in two or more specialties. Taking another test will not change their credentials. In fact, having credentials in two specialties in many ways carries greater prestige and has greater versatility than a subspecialty in C-L since members of this group are accepted by at least two guilds, can practice in two independent areas of medicine if they choose, can be reimbursed for services by both psychiatric and non-psychiatric payers, and can implement add to the quality of care their patients receive because of their expertise. Furthermore, they are not hampered by the need to take additional training after residency to be recognized for the contributions that they make and already take two certifying examinations which in concert are significantly more difficult than an examination that would be produced for a C-L subspecialty.

It is now time for those with combined training to think about how they are going to forward their own agenda. They can do this while they support the efforts of their colleagues in C-L psychiatry who wish to be recognized for their specialty contributions to patients with medical and psychiatric illness. We are not adversaries. We just approach our interest in caring for these complicated patients in different ways.

So what can we do? First, we should recognize that we already have enough examinations to take. Let's concentrate on completing and remaining certified in our chosen combined disciplines. Second, let's establish our own name recognition. I have always called myself an "internist-psychiatrist" with the expectation that people will recognize by my saying that that I practice both. We now have family practice-psychiatrists, pediatric-psychiatrists, and neurologist-psychiatrists who can call themselves these names. With proper publicity about what this means, our colleagues and patients (and payers) will come to recognize the added value we bring to patient care.

Third, we can focus our efforts on developing clinical settings in which our special expertise can be best utilized. For instance, internist-psychiatrists may be inclined to coordinate and develop inpatient integrated treatment programs while family practice-psychiatrists would be more interested in outpatient integrated programs. Others may choose to focus on the care of patients with medically compromised eating disorders, assessment and treatment of chronic pain complaints, patients with delirium, etc.

These are just some suggestions about areas in which the coordinated effort and thought of both those with C-L subspecialty status and combined training can lead to innovative improvements in the care our patients receive. To this point, those with combined training have forged an alliance with C-L psychiatrists. This should continue since both bring valuable skills to the clinical arena. Now, however, is also a time when those with combined training develop and foster their own identity, moving the field of medicine forward using their specially honed knowledge and experience.