Academic Psychiatry 28:1-3, March 2004
© 2004 Academic Psychiatry
What's Special About Psychiatric Subspecialties?
Joyce A. Tinsley, M.D.
Dr. Tinsley is Director of Psychiatric Residency Training and Associate Professor of Psychiatry at the University of Connecticut, Farmington, Connecticut. Address correspondence to Dr. Tinsley, University of Connecticut Health Center, 263 Farmington, CT 06030-1935; tinsley{at}psychiatry.uchc.edu (E-mail).
History
For 30 years, from 1959 to 1989, child psychiatry was the only psychiatric subspecialty recognized by the American Board of Psychiatry and Neurology (ABPN). One compelling reason for this is that specialization within psychiatry paralleled specialization in other medical fields. Physician interest in specializing heightened after World War II, as prestige and income became associated with specialty credentials. During this period, psychoanalysts explored the possibility of ABPN certification (1), and representatives of child psychiatry proposed subspecialty status (1). The ABPN recognized the subspecialty of Child Psychiatry in 1959; however, psychoanalytic representatives and ABPN officials were unable to agree on the specifics of board certification.
During the last century, medical practice maintained momentum toward a specialist model. Its course was not linear, however. In a 2000 Journal of the American Medical Association (JAMA) article, Donini-Lenhoff and Hedrick (3) reviewed the history of specialization in medical education. Donini-Lenhoff and Hedrick (3) reported that 14 medical specialties existed in 1927. In 2000, the Accreditation Council for Graduate Medical Education listed 107 specialties in which physicians could train. The sharpest rise in the number of approved medical subspecialties occurred after 1985, and the newer psychiatric subspecialties were among them.
In concurrence with the American Board of Medical Specialties (ABMS), ABPN approved certification for the subspecialty of geriatric psychiatry in 1989, addiction psychiatry in 1991, and forensic psychiatry in 1992. Pain management was recognized as a multidisciplinary specialty in 1998, with cosponsorship of ABPN and the boards of Anesthesia and Physical Medicine and Rehabilitation. Most recently, psychosomatic medicine achieved recognition as the newest psychiatric subspecialty.
Is It Special?
Not everyone agrees with the proliferation of subspecialties in medicine. The debates surrounding whether to train more generalists or more specialists are well known, with good arguments on both sides. Proponents of training more generalists raise issues of prevention and meeting basic needs of the population. On the other hand, a medical information explosion seems to demand more specialists to master it. Similar generalist-specialist arguments are appropriate for psychiatry. The essence of these arguments has not changed since the movement toward specialty medicine began during the turn of the century.
If history is our guide, then good arguments on both sides of the debate will continue, and they should. The appropriate mix of physicians, including psychiatrists, is not static. Cooper (4), who believes there is an impending shortage of specialists, cites four broad trends influencing the number of physicians that are needed: economic expansion, physician work-effort, services provided by nonphysician clinicians, and growth in the United States population. In addition, demographics are changing. An example is the aging baby boomers that are expected to increase demands for geriatric expertise and the delivery of sophisticated medical care. On the other hand, rising healthcare costs argue for more aggressive prevention and health maintenance.
Perhaps the best argument for certification in any field of medicine is to help the public distinguish between doctors who are qualified at an advanced level and those who are not. The ABMS reports that 25% of U.S. physicians have subspecialty credentials, in addition to specialty training.
Another favorable argument is that specialists often teach their topic with greater enthusiasm than other instructors. An additional hope is for research in the newly designated subspecialty to flourish. Overall, ABMS endorsement seems to elevate a subspecialty's status in medicine above what it might have been otherwise.
The need for specialists to care for an aging population is an effective argument for geriatrics. Addiction proponents follow similar reasoning in citing the large numbers of substance abusers in the population, as indicated by an APA-endorsed position statement on training needs in addiction psychiatry (5). This document underscores the importance of psychiatric residency and advanced training in addictions and of psychiatrists to provide leadership for the multidisciplinary teams that are characteristic of the field. It further emphasizes the manpower needed for consultation, academic teaching, and research in the field.
An article in Medicine & Law (6) took a different approach in its argument for the subspecialty of forensic psychiatry by pointing to the advantages of having defined parameters of knowledge and skills, rather than having experts acquire skills in a haphazard manner. In particular, the certified forensic psychiatrist should be skilled in making assessments; drafting reports; giving evidence in court; and acquiring knowledge of mental health laws, institutions, and the legal system. This concept captures the critical intent of accreditation of all specialty and subspecialty training programs and of board certification, which is recognizing a body of knowledge and setting a minimum standard of expertise for specialists.
Challenges for Subspecialty Training
There are a number of problems for subspecialties in psychiatry. Once recognized, a specialty must attract trainees to its programs. Both specialties of geriatrics and addictions have had disappointments in filling programs, especially with qualified U.S. medical graduates. The training of international medical graduates on J-1 Visas presents a problem in determining the physician workforce in the United States. Additionally, the rate at which certified specialists will recertify once their temporary certificates expire is unclear. In a 2003 article, Juul and Scheiber (7) reported that 2,595 certificates have been awarded in geriatric psychiatry; however, only 63% of those eligible to recertify have done so.
The potential for competition between specialties was clear when consultation-liaison (C/L) made a bid for subspecialty status. Recently, ABMS approved the ABPN recommendation to recognize C/L as a subspecialty under its new name "psychosomatic medicine," but there was considerable debate in the field prior to approval. There were concerns that the scope of C/L was too broad, that it overlapped with geriatrics, and that consultations are part of the "bread and butter" of general psychiatry. Some educators in approved subspecialties feared competition for applicants with the addition of another subspecialty. Nevertheless, the argument in favor of a psychiatric subspecialty specifically devoted to the complex care of the medically ill was accepted, with compromise on the name of the new subspecialty.
Two of the educational challenges for subspecialists are: 1) acquainting general program directors and other educators with subspecialty training programs and 2) sharing ideas about how to teach medical students and residents about these topic areas. This issue of Academic Psychiatry aims to provide information and stimulate thought by presenting papers on a variety of subspecialty training and content areas. Each subspecialty is exciting enough to stand alone. Perhaps putting them together in a single issue is a statement about how closely linked one subspecialty is to another in contributing to this expanding and attractive field of medicine, with its many facets of practice and research and education.
REFERENCES
- Hollender MH: Certification for psychoanalysis. In: Hollender MH. The American Board of Psychiatry and Neurology: The First Fifty Years. The American Board of Psychiatry and Neurology, Chicago Ill, 1991
- Beiser HR: Certification in child and adolescent psychiatry. . In: Hollender MH. The American Board of Psychiatry and Neurology: The First Fifty Years. The American Board of Psychiatry and Neurology, Chicago Ill, 1991
- Donini-Lenhoff FG, Hedrick HL: Growth of specialization in graduate medical education. JAMA 284 (10):1284–1289, 2000
- Cooper RA: There's a shortage of specialists: is anyone listening? Academic Medicine 77:761–766, 2002
- Anonymous: Position statement on training needs in addiction psychiatry. American Journal of Psychiatry 153 (6):852–3, 1996
- Hashman K: Post-graduate training in forensic psychiatry. Medicine & Law 13 (3–4):369–72, 1994
- Juul D, Scheiber SC: Subspecialty certification in geriatric psychiatry. American Journal of Geriatric Psychiatry 11(3):351–5, 2003
This article has been cited by other articles:
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R. E. Levine, D. L. Carlson, R. H. Rosenthal, K. A. Clegg, and R. D. Crosby
Usage of the National Board of Medical Examiners Subject Test in Psychiatry by U.S. and Canadian Clerkships
Acad Psychiatry,
March 1, 2005;
29(1):
52 - 57.
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