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A very modest proposal for 1990s CL psychiatry
Commentary and Perspective From time to time, the Journal receives manuscripts that can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.
A Very Modest Proposal for 1990s C/L Psychiatry Myron F. Weiner, M.D., John Sadler, M.D., Barry J. Fenton, M.D., Michael C. Fitzpatrick, M.D., J. Douglas Crowder, M.D., and Karl Goodkin, M.D., Ph.D.
Abstract: The prediction that consultation-liaison psychiatry would play an integral role in the management of all medicall surgical patients in large hospitals has not come to pass. The primary reason is that no adequafefinding mechanism has ever been found to support such a large endeavor. The economic climate as we enter the 1990s makes such funding even less likely. The authors suggest that GIL psychiatry accept a lesser role, largely confined to teaching hospitals. That role, which has been successful at a large public teaching hospital for nearly 10 years, encompasses serving as a primary psychiatric teaching site for medical students, a primary teaching site for psychiatry residents and other postgraduate physicians rotating through psychiatry, a source of innovative dispositions for medically ill psychiatric patients, and a source of opportunity for inferdisciplinary research.
A Very Modest Proposal for 1990s C/L Psychiatry The notion that psychiatrists might contribute greatly to the medical management of patients in general hospitals was first proposed in 1929 [l]. It rapidly gained currency, and by 1936 it was predicted that psychiatrists would soon be required on all medical and surgical units [2]. That time has never come. In 1982, Hales and Fink wrote a thoughtful arFrom the University of Texas Southwestern Medical Center at Dallas, Department of Psychiatry, Dallas, Texas. Address reprint requests to: Myron F. Weiner, M.D., Professor and Vice Chairman of Psychiatry; and Chief, Consultationkiaison Division, University of Texas Southwestern Medical Center at Dallas, 5323 Harrv Hines Boulevard, Dallas, TX 75235-9070.
General Hospital Psychiatry 11,231-W, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
title entitled, “A Modest Proposal for Consultation/Liaison Psychiatry in the 1980s” [3]. They proposed that all general hospitals with more than 350 beds have fully staffed C/L services and that these services be funded through third-party reimbursement formulas as an integral hospital-based service. They suggested that without such a financial base, C/L psychiatry might suffer the same fate as the community mental health movement. To date, we have yet to find that financial base. In almost every instance, formal psychiatric liaison activities have failed, largely due to lack of funding [4]. Third-party payors, as exemplified by Medicare, pay for only “direct” patient service and in that way negate the value of liaison work. Medicare has still further crippled teaching institutions by paying only for patient contacts by faculty-level physicians documented by attending notes and signatures. Thus, the psychiatric trainee’s function as an extender of the faculty physician is not reimbursed. Paradoxically, psychiatric inpatient units in general hospitals are flourishing. They have become profit centers for hospitals whose medical and surgical patients’ stays are now more closely monitored by third-party payors through such mechanisms as diagnostic-related groups (DRGs). At Parkland Hospital, psychiatrists are welcomed as consultants in selection of patients for various transplant procedures, the management of delirium and other in-hospital behavior problems, and the management and disposition of suicidal
231 ISSN 0163~8343/89/$3.50
M. F. Weiner et al.
patients and patients who are mentally ill. Our referring physicians’ concern is to deal in the most direct and effective chemical and mechanical ways with patients who are sicker than before in a hospital climate that has become increasingly tense because of nursing shortages, increases in malpractice suits, and the AIDS epidemic. Psychiatric consultants are not asked to serve as advocates or leaders in broad-based humanistic patient care, but as helpers in cost-effective and efficient patient care. Hospitals respond in the same way. Nonprofit institutions are wary of additional costs; forprofit institutions do not fund programs without obvious financial benefit. Third-party payors are also not interested, despite evidence that routine psychiatric involvement can reduce psychiatric comorbidity and length of stay [5]. What, then, is the role of C/L psychiatrists if they cannot become members of the medical team, as proposed by Beigler et al. [6], or become a major component of the mental health system, as envisioned by Lipowski [7]? The authors make a proposal even more modest than that of Hales and Fink. We propose that C/L psychiatrists, who are de facto academic psychiatrists, confine their endeavors to (1) teaching medical students, (2) teaching psychiatric residents and residents from other specialties who rotate through psychiatry, (3) designing creative dispositions for patients requiring combined medical-psychiatric treatment, and (4) participating in interdisciplinary research. This proposal is based on the activities of the C/L service at Parkland Memorial Hospital. We suggest that the following description of our activities may be a realistic model for other psychiatrists operating under the same circumstances. Parkland Hospital is a city-county hospital serving the 250,000 medically indigent persons of Dallas County. It is the principal teaching hospital of Southwestern Medical School, whose faculty are responsible through the housestaff for the delivery of health care at Parkland. Parkland has traditionally paid housestaff salaries but not psychiatric faculty salaries. A medical team model of C/L has been operative at Parkland since 1979 [8]. Each team is headed by a senior psychiatry resident and includes one or two medical students, neurology residents rotating on psychiatry, and a part-time clinical psychology trainee. A C/L faculty physician rounds regularly with each of the three teams. One team covers the surgical services, including a large burn unit. A second team covers 232
OB/GYN and internal medicine. The third team covers medical intensive care, neurology, neurosurgery, and physical medicine. Our AIDS consultation service sees outpatients in the AIDS Clinic and consists of a faculty member and residents on elective rotation. One faculty member floats between services and is available for special projects. The senior psychiatry resident directs the activity of each team; the attending serves as consultant. Our liaison activities are limited to attending a weekly burn unit conference and conducting a support group for burn unit nurses. We conduct a patient group on the renal transplantation/dialysis unit, a support group for AIDS clinic personnel, and a support group for long-term AIDS survivors. We are able to bill AIDS patients with Medicare coverage because they are seen directly by the faculty psychiatrist. We cannot bill for the renal group because those individuals are not seen directly by faculty. Psychiatric faculty physicians are full-time employees of Southwestern Medical School. The C/L faculty members’ direct supervision of patient care at Parkland, including on-site teaching of residents and medical students, requires about 10 hours per week per faculty member. The remainder of their time is spent in other academic activities, research, and direct care of private patients. Faculty members’ salaries are derived from various combinations of state funds, Parkland funds, private practice income, contractual income, and grants. All faculty members receive some state salary. Two are partially funded by Parkland. All have private practice income credited toward their salary. Two have contracts to do special work for the federal government (FBI and Worker’s Compensation) and one has partial salary support from an NIH research grant. The income derived from charges made to Parkland patients flows to the Department. Our collection rate at Parkland is 25% (higher than the psychiatric inpatient unit or outpatient clinic), but our C/L Service income has never exceeded $30,000 in 1 year.
Medical Student Teaching The C/L Service is a primary teaching site for medical students, who are assigned to psychiatry 4 weeks during their junior year. The C/L Service has many advantages over other psychiatric training sites. Response to treatment is prompt (as in treating delirium) and medical students are
A Very Modest Proposal
able to see that psychiatrists make potent interventions. Psychiatrists are also seen to use their medical knowledge, for example, in prescribing antidepressant agents based on patients’ cardiovascular status and possible drug interactions. Students come to understand that psychiatric problems are an integral part of medicine and also come to recognize that awareness of the patient as a person is critical to prescribing a treatment.
Teaching House Officers Psychiatric residents spend 6 months of their fourth year on C/L, devoting approximately 25 hours per week to C/L activities. Each spends 3 months on two of four services, three at Parkland and one at a private general hospital. The consultation load is 60-80 new consultations per month and 2-3 follow-up visits per patient. The consultation rate in the AIDS clinic is 10 per month, with 10 follow-up visits, and is increasing rapidly. Neurology residents spend 1 month on the C/L service. They are assigned to the Neurology team so they can see and deal with their own patients from a psychiatric perspective. They are allowed to function as autonomously as their sophistication and interest level allows. Investing them with responsibility as consultants keeps them alert, interested, and learning.
Implementing Creative Dispositions There is enormous pressure for beds at Parkland. This pressure for beds has given rise to collaborative efforts with other physicians, nursing, administration, the Dallas County Mental Health/ Mental Retardation Center, the nearby state hospital, and the judge of the county probate (mental illness) court. Hospital personnel are grateful for help in transferring patients to other facilities when their need for intensive medical treatment is over. Arranging these transfers initially required complicated negotiations between facilities, but we have helped formulate policies that facilitate cooperation among institutions. The process of negotiation has established us as pragmatic physicians who are also concerned with the quality of health care, and has led Parkland to assign us an office and patient interview space for our residents and other trainees.
Interdisciplinary Research Interdisciplinary research involvement began with consultation and was enhanced through faculty members’ specialization, their flexibility of response, and their sensitivity to shared clinical problems. Interdisciplinary research in turn increased the use of psychiatrists as consultants. We began by providing practical consultation advice and by stimulating curiosity about patient management. When possible, the psychiatric consultation included attending-to-attending interaction. For example, our surgery attending engaged the surgery staff in considering the relationship between family structure and outcome of ICU treatment and has initiated a similar study in the burn unit. A study of the impact of support groups on women treated for breast cancer also involved surgeons in addressing the emotional needs of their patients. Specialization of the C/L attendings also helped them to develop a reputation in the community that generated referral of patients with specific problems and funding for specific research projects. For example, our surgical liaison’s work on support groups for breast cancer patients has been assisted and funded by the American Cancer Society. Our neurologic/neurosurgical liaison was enlisted by the neurosurgical staff in assessing presurgical and postsurgical issues in patients receiving adrenal medullary transplants for Parkinson’s disease. In-hospital and community contacts played a role in the development of that relationship. Our neurologic liaison had had experience in managing the psychiatric complications of Parkinson’s disease. Thus, being approached by the neurosurgeon and neurologist was a natural consequence. Moreover, his patient education efforts had made him known to the Dallas Area Parkinson Society, which also recommended him when the organization was approached for funding by the neurosurgical and neurologic staff. Another C/L faculty member’s interest in groups led to a series of publications on support groups for nurses and an institutionally funded collaboration with a pediatrician on the effects of support groups on neonatal ICU care. Flexibility in responding to the changing needs of the medical community was essential. One C/L attending made himself available as part of a Robert Wood Johnson-funded geriatric assessment team. When the grant expired, the portion of his salary that had been funded from the grant was underwritten by the hospital. Another C/L attending re233
M. F. Weiner et al.
sponded to a call from the department of internal medicine’s to collaborate in submitting an interdisciplinary AIDS grant that included the departments of neurology and pathology. Although the submitted protocol was not funded, the way was paved for a new faculty member with interest in psychoimmunology to become established in the AIDS clinic and to begin his own research project. This has also stimulated the interest of psychology graduate students and of psychiatric residents, who now have the option of an elective in AIDS consultation. An academic challenge has enhanced patient care delivery. Sensitivity to problems shared by psychiatry and other medical specialties has also been helpful in establishing interdisciplinary research. For example, our internal medicine liaison psychiatrist and his medicine attending were puzzled at the lack of relationship between the severity of panic symptoms and the severity of mitral valve prolapse. This led to a funded psychiatric, physiologic, and biochemical study in which panic attacks were provoked by lactate infusion in normals and patients with mitral valve prolapse [9]. Interdisciplinary research also stimulates interest in the psychiatric aspects of patient care. One attending’s interest in Alzheimer’s disease research led to the establishment with the neurology department of a fee-for-service dementia clinic. The clinic now receives large numbers of requests for help in dealing with the emotional impact of dementing illness on both patients and their families. The dementia clinic had a still further stimulating effect on research, providing the service component that enabled the success of an Alzheimer’s disease research center proposal after two earlier submissions that were unsuccessful because they had involved only basic research. It is our impression that efforts at interdisciplinary research are more successful if our faculty has research training or a special area of expertise in addition to C/L. We think it wise that potential faculty members spend at least 1 year in research outside of C/L psychiatry, as this develops their ability to frame scientific questions and to carry out interdisciplinary research. One attending has had a forensic fellowship, another has one in geriatrics, and a third has both research training in psychiatry and a Ph.D. in psychology. That background allowed the last person to focus sharply and to ini-
234
tiate several grant applications within his first year as a faculty member.
Conclusions We, as C/L psychiatrists, have a modest role in the care of medical-surgical patients at Parkland Hospital. We do not foresee a larger role for ourselves in view of the realities of medical practice in the 1990s. Our position as teachers is secure, based on the comments we receive from medical students and house officers. We are accepted as collaborative colleagues by nonpsychiatrist physicians and as helpful physicians by hospital administration and nursing staff. And we are increasingly invited to participate with nonpsychiatrist colleagues in their research. Our research involvement also feeds back into our clinical work, with substantial numbers of referrals from the physicians with whom we collaborate. The path that appears open to further expansion is interdisciplinary research, but that path can be followed only if we are academically prepared.
References 1. Henry GW: Some aspects of psychiatry in general hospital practice. Am J Psychiatry 86481-489, 1929 2. Dunbar FH, Wolfe T’P, Rioch, J Meek: Psychiatric aspects of medical problems. Am J Psychiatry 93:649689, 1936 3. Hales RE, Fink T’S: A modest proposal for consultation/liaison psychiatry in the 1980s. Am J Psychiatry 139:1015-1021, 1982 4. Fenton BJ, Guggenheim FG: Consultatiotiaison psychiatry and funding: Why can’t Alice find Wonderland? Gen Hosp Psychiatry 3:255-260, 1981 5. Levitan SJ, Kornfeld DS: A study of liaison-psychiatry effectiveness: Clinical and cost benefits. Am J Psychiatry 138:790-793, 1981 6. Beigler JS, Robbins FP, Lane EW, Miller AA, Samelson C: Report on Liaison Psychiatry at Michael Reese Hospital, 1950-1958. Arch Neurol Psychiatry 81:733746, 1959 7. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom Med 29:153-171, 1967 8. Guggenheim FG: The use of the medical team model in a consultation-liaison teaching service. Gen Hosp Psychiatry 4219-224, 1982 9. Gaffney FA, Fenton BJ, Lane LD, et al: Hemodynamics, ventilatory and biochemical responses of panic patients and normal controls with sodium lactate infusion and spontaneous panic attacks. Arch Gen Psychiatry, 45:53-60, 1988
A Very Modest Proposal for 1990s C/L Psychiatry Myron F. Weiner, M.D., John Sadler, M.D., Barry J. Fenton, M.D., Michael C. Fitzpatrick, M.D., J. Douglas Crowder, M.D., and Karl Goodkin, M.D., Ph.D.
Abstract: The prediction that consultation-liaison psychiatry would play an integral role in the management of all medicall surgical patients in large hospitals has not come to pass. The primary reason is that no adequafefinding mechanism has ever been found to support such a large endeavor. The economic climate as we enter the 1990s makes such funding even less likely. The authors suggest that GIL psychiatry accept a lesser role, largely confined to teaching hospitals. That role, which has been successful at a large public teaching hospital for nearly 10 years, encompasses serving as a primary psychiatric teaching site for medical students, a primary teaching site for psychiatry residents and other postgraduate physicians rotating through psychiatry, a source of innovative dispositions for medically ill psychiatric patients, and a source of opportunity for inferdisciplinary research.
A Very Modest Proposal for 1990s C/L Psychiatry The notion that psychiatrists might contribute greatly to the medical management of patients in general hospitals was first proposed in 1929 [l]. It rapidly gained currency, and by 1936 it was predicted that psychiatrists would soon be required on all medical and surgical units [2]. That time has never come. In 1982, Hales and Fink wrote a thoughtful arFrom the University of Texas Southwestern Medical Center at Dallas, Department of Psychiatry, Dallas, Texas. Address reprint requests to: Myron F. Weiner, M.D., Professor and Vice Chairman of Psychiatry; and Chief, Consultationkiaison Division, University of Texas Southwestern Medical Center at Dallas, 5323 Harrv Hines Boulevard, Dallas, TX 75235-9070.
General Hospital Psychiatry 11,231-W, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
title entitled, “A Modest Proposal for Consultation/Liaison Psychiatry in the 1980s” [3]. They proposed that all general hospitals with more than 350 beds have fully staffed C/L services and that these services be funded through third-party reimbursement formulas as an integral hospital-based service. They suggested that without such a financial base, C/L psychiatry might suffer the same fate as the community mental health movement. To date, we have yet to find that financial base. In almost every instance, formal psychiatric liaison activities have failed, largely due to lack of funding [4]. Third-party payors, as exemplified by Medicare, pay for only “direct” patient service and in that way negate the value of liaison work. Medicare has still further crippled teaching institutions by paying only for patient contacts by faculty-level physicians documented by attending notes and signatures. Thus, the psychiatric trainee’s function as an extender of the faculty physician is not reimbursed. Paradoxically, psychiatric inpatient units in general hospitals are flourishing. They have become profit centers for hospitals whose medical and surgical patients’ stays are now more closely monitored by third-party payors through such mechanisms as diagnostic-related groups (DRGs). At Parkland Hospital, psychiatrists are welcomed as consultants in selection of patients for various transplant procedures, the management of delirium and other in-hospital behavior problems, and the management and disposition of suicidal
231 ISSN 0163~8343/89/$3.50
M. F. Weiner et al.
patients and patients who are mentally ill. Our referring physicians’ concern is to deal in the most direct and effective chemical and mechanical ways with patients who are sicker than before in a hospital climate that has become increasingly tense because of nursing shortages, increases in malpractice suits, and the AIDS epidemic. Psychiatric consultants are not asked to serve as advocates or leaders in broad-based humanistic patient care, but as helpers in cost-effective and efficient patient care. Hospitals respond in the same way. Nonprofit institutions are wary of additional costs; forprofit institutions do not fund programs without obvious financial benefit. Third-party payors are also not interested, despite evidence that routine psychiatric involvement can reduce psychiatric comorbidity and length of stay [5]. What, then, is the role of C/L psychiatrists if they cannot become members of the medical team, as proposed by Beigler et al. [6], or become a major component of the mental health system, as envisioned by Lipowski [7]? The authors make a proposal even more modest than that of Hales and Fink. We propose that C/L psychiatrists, who are de facto academic psychiatrists, confine their endeavors to (1) teaching medical students, (2) teaching psychiatric residents and residents from other specialties who rotate through psychiatry, (3) designing creative dispositions for patients requiring combined medical-psychiatric treatment, and (4) participating in interdisciplinary research. This proposal is based on the activities of the C/L service at Parkland Memorial Hospital. We suggest that the following description of our activities may be a realistic model for other psychiatrists operating under the same circumstances. Parkland Hospital is a city-county hospital serving the 250,000 medically indigent persons of Dallas County. It is the principal teaching hospital of Southwestern Medical School, whose faculty are responsible through the housestaff for the delivery of health care at Parkland. Parkland has traditionally paid housestaff salaries but not psychiatric faculty salaries. A medical team model of C/L has been operative at Parkland since 1979 [8]. Each team is headed by a senior psychiatry resident and includes one or two medical students, neurology residents rotating on psychiatry, and a part-time clinical psychology trainee. A C/L faculty physician rounds regularly with each of the three teams. One team covers the surgical services, including a large burn unit. A second team covers 232
OB/GYN and internal medicine. The third team covers medical intensive care, neurology, neurosurgery, and physical medicine. Our AIDS consultation service sees outpatients in the AIDS Clinic and consists of a faculty member and residents on elective rotation. One faculty member floats between services and is available for special projects. The senior psychiatry resident directs the activity of each team; the attending serves as consultant. Our liaison activities are limited to attending a weekly burn unit conference and conducting a support group for burn unit nurses. We conduct a patient group on the renal transplantation/dialysis unit, a support group for AIDS clinic personnel, and a support group for long-term AIDS survivors. We are able to bill AIDS patients with Medicare coverage because they are seen directly by the faculty psychiatrist. We cannot bill for the renal group because those individuals are not seen directly by faculty. Psychiatric faculty physicians are full-time employees of Southwestern Medical School. The C/L faculty members’ direct supervision of patient care at Parkland, including on-site teaching of residents and medical students, requires about 10 hours per week per faculty member. The remainder of their time is spent in other academic activities, research, and direct care of private patients. Faculty members’ salaries are derived from various combinations of state funds, Parkland funds, private practice income, contractual income, and grants. All faculty members receive some state salary. Two are partially funded by Parkland. All have private practice income credited toward their salary. Two have contracts to do special work for the federal government (FBI and Worker’s Compensation) and one has partial salary support from an NIH research grant. The income derived from charges made to Parkland patients flows to the Department. Our collection rate at Parkland is 25% (higher than the psychiatric inpatient unit or outpatient clinic), but our C/L Service income has never exceeded $30,000 in 1 year.
Medical Student Teaching The C/L Service is a primary teaching site for medical students, who are assigned to psychiatry 4 weeks during their junior year. The C/L Service has many advantages over other psychiatric training sites. Response to treatment is prompt (as in treating delirium) and medical students are
A Very Modest Proposal
able to see that psychiatrists make potent interventions. Psychiatrists are also seen to use their medical knowledge, for example, in prescribing antidepressant agents based on patients’ cardiovascular status and possible drug interactions. Students come to understand that psychiatric problems are an integral part of medicine and also come to recognize that awareness of the patient as a person is critical to prescribing a treatment.
Teaching House Officers Psychiatric residents spend 6 months of their fourth year on C/L, devoting approximately 25 hours per week to C/L activities. Each spends 3 months on two of four services, three at Parkland and one at a private general hospital. The consultation load is 60-80 new consultations per month and 2-3 follow-up visits per patient. The consultation rate in the AIDS clinic is 10 per month, with 10 follow-up visits, and is increasing rapidly. Neurology residents spend 1 month on the C/L service. They are assigned to the Neurology team so they can see and deal with their own patients from a psychiatric perspective. They are allowed to function as autonomously as their sophistication and interest level allows. Investing them with responsibility as consultants keeps them alert, interested, and learning.
Implementing Creative Dispositions There is enormous pressure for beds at Parkland. This pressure for beds has given rise to collaborative efforts with other physicians, nursing, administration, the Dallas County Mental Health/ Mental Retardation Center, the nearby state hospital, and the judge of the county probate (mental illness) court. Hospital personnel are grateful for help in transferring patients to other facilities when their need for intensive medical treatment is over. Arranging these transfers initially required complicated negotiations between facilities, but we have helped formulate policies that facilitate cooperation among institutions. The process of negotiation has established us as pragmatic physicians who are also concerned with the quality of health care, and has led Parkland to assign us an office and patient interview space for our residents and other trainees.
Interdisciplinary Research Interdisciplinary research involvement began with consultation and was enhanced through faculty members’ specialization, their flexibility of response, and their sensitivity to shared clinical problems. Interdisciplinary research in turn increased the use of psychiatrists as consultants. We began by providing practical consultation advice and by stimulating curiosity about patient management. When possible, the psychiatric consultation included attending-to-attending interaction. For example, our surgery attending engaged the surgery staff in considering the relationship between family structure and outcome of ICU treatment and has initiated a similar study in the burn unit. A study of the impact of support groups on women treated for breast cancer also involved surgeons in addressing the emotional needs of their patients. Specialization of the C/L attendings also helped them to develop a reputation in the community that generated referral of patients with specific problems and funding for specific research projects. For example, our surgical liaison’s work on support groups for breast cancer patients has been assisted and funded by the American Cancer Society. Our neurologic/neurosurgical liaison was enlisted by the neurosurgical staff in assessing presurgical and postsurgical issues in patients receiving adrenal medullary transplants for Parkinson’s disease. In-hospital and community contacts played a role in the development of that relationship. Our neurologic liaison had had experience in managing the psychiatric complications of Parkinson’s disease. Thus, being approached by the neurosurgeon and neurologist was a natural consequence. Moreover, his patient education efforts had made him known to the Dallas Area Parkinson Society, which also recommended him when the organization was approached for funding by the neurosurgical and neurologic staff. Another C/L faculty member’s interest in groups led to a series of publications on support groups for nurses and an institutionally funded collaboration with a pediatrician on the effects of support groups on neonatal ICU care. Flexibility in responding to the changing needs of the medical community was essential. One C/L attending made himself available as part of a Robert Wood Johnson-funded geriatric assessment team. When the grant expired, the portion of his salary that had been funded from the grant was underwritten by the hospital. Another C/L attending re233
M. F. Weiner et al.
sponded to a call from the department of internal medicine’s to collaborate in submitting an interdisciplinary AIDS grant that included the departments of neurology and pathology. Although the submitted protocol was not funded, the way was paved for a new faculty member with interest in psychoimmunology to become established in the AIDS clinic and to begin his own research project. This has also stimulated the interest of psychology graduate students and of psychiatric residents, who now have the option of an elective in AIDS consultation. An academic challenge has enhanced patient care delivery. Sensitivity to problems shared by psychiatry and other medical specialties has also been helpful in establishing interdisciplinary research. For example, our internal medicine liaison psychiatrist and his medicine attending were puzzled at the lack of relationship between the severity of panic symptoms and the severity of mitral valve prolapse. This led to a funded psychiatric, physiologic, and biochemical study in which panic attacks were provoked by lactate infusion in normals and patients with mitral valve prolapse [9]. Interdisciplinary research also stimulates interest in the psychiatric aspects of patient care. One attending’s interest in Alzheimer’s disease research led to the establishment with the neurology department of a fee-for-service dementia clinic. The clinic now receives large numbers of requests for help in dealing with the emotional impact of dementing illness on both patients and their families. The dementia clinic had a still further stimulating effect on research, providing the service component that enabled the success of an Alzheimer’s disease research center proposal after two earlier submissions that were unsuccessful because they had involved only basic research. It is our impression that efforts at interdisciplinary research are more successful if our faculty has research training or a special area of expertise in addition to C/L. We think it wise that potential faculty members spend at least 1 year in research outside of C/L psychiatry, as this develops their ability to frame scientific questions and to carry out interdisciplinary research. One attending has had a forensic fellowship, another has one in geriatrics, and a third has both research training in psychiatry and a Ph.D. in psychology. That background allowed the last person to focus sharply and to ini-
234
tiate several grant applications within his first year as a faculty member.
Conclusions We, as C/L psychiatrists, have a modest role in the care of medical-surgical patients at Parkland Hospital. We do not foresee a larger role for ourselves in view of the realities of medical practice in the 1990s. Our position as teachers is secure, based on the comments we receive from medical students and house officers. We are accepted as collaborative colleagues by nonpsychiatrist physicians and as helpful physicians by hospital administration and nursing staff. And we are increasingly invited to participate with nonpsychiatrist colleagues in their research. Our research involvement also feeds back into our clinical work, with substantial numbers of referrals from the physicians with whom we collaborate. The path that appears open to further expansion is interdisciplinary research, but that path can be followed only if we are academically prepared.
References 1. Henry GW: Some aspects of psychiatry in general hospital practice. Am J Psychiatry 86481-489, 1929 2. Dunbar FH, Wolfe T’P, Rioch, J Meek: Psychiatric aspects of medical problems. Am J Psychiatry 93:649689, 1936 3. Hales RE, Fink T’S: A modest proposal for consultation/liaison psychiatry in the 1980s. Am J Psychiatry 139:1015-1021, 1982 4. Fenton BJ, Guggenheim FG: Consultatiotiaison psychiatry and funding: Why can’t Alice find Wonderland? Gen Hosp Psychiatry 3:255-260, 1981 5. Levitan SJ, Kornfeld DS: A study of liaison-psychiatry effectiveness: Clinical and cost benefits. Am J Psychiatry 138:790-793, 1981 6. Beigler JS, Robbins FP, Lane EW, Miller AA, Samelson C: Report on Liaison Psychiatry at Michael Reese Hospital, 1950-1958. Arch Neurol Psychiatry 81:733746, 1959 7. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom Med 29:153-171, 1967 8. Guggenheim FG: The use of the medical team model in a consultation-liaison teaching service. Gen Hosp Psychiatry 4219-224, 1982 9. Gaffney FA, Fenton BJ, Lane LD, et al: Hemodynamics, ventilatory and biochemical responses of panic patients and normal controls with sodium lactate infusion and spontaneous panic attacks. Arch Gen Psychiatry, 45:53-60, 1988