EDITORIAL
General Hospital Inpatient Psychiatry in the 1990s: Problems and Possibilities Paul Summergrad,
M.D.”
Inpatient psychiatry in the general hospital occupies an unusual position. The development of general hospital inpatient services in the 1930s and their subsequent growth have been important for the clinical, academic and economic success of general hospital psychiatry. Whereas consultation-liaison activities have provided an important service to the general hospital, especially as a point of direct contact with the medical staff, inpatient services have been significant in other ways. Overcoming skepticism about the capacity of the general hospital to care for psychiatric patients at all, general hospital inpatient units have helped to enlarge the scope of psychiatric inpatient care, have served as a location for early research in biologic psychiatry, and have been a major source of income for many departments of psychiatry [l]. Indeed, general hospitals treat both in scatter beds and on discrete general hospital units approximately 60% of all patients hospitalized in the United States with a primary psychiatric diagnosis [2]. General hospital inpatient psychiatry has often been buffeted by theoretical fashions and trends, but these have affected psychiatry as a whole. For example, the growth of general hospital inpatient psychiatry was stimulated by the post-World War II success of the then predominant psychodynamic model. Then, in the 1950s and 196Os, milieu models of inpatient psychiatric care were imported from state hospitals to general hospitals. The wholesale and often uncritical entry of these models from settings where they appropriately attempted to address problems of custodial care to general hospitals occurred with seemingly little awareness of the *Director, eral Hospital; ical School.
Inpatient Assistant
Psychiatric Professor
Service, Massachusetts of Psychiatry, Harvard
Gown/ Hosprfai Psydliafry 13, 79-82, IYYI cj 1991 Elsevier S&nce Publishing Co., Inc. hS.‘rA\,rnurottheAmericds,Ne~‘York,NY 10010
GenMed-
different culture and needs of the latter setting. Others have seen general hospital psychiatry units as the successor institution to the state hospital, suggesting that care of the chronically mentally ill should be a prime responsibility of such units. Again, these suggestions have often been made with little cognizance of how these goals might fit into the patterns of care and organization of such units [3,4,5]. Recently, as part of the much needed remedicalization of psychiatry, medical-psychiatric units have been created [6,7]. These units emphasize bedside rounding, physician expertise, and management of medically complex and psychiatrically ill patients in the only setting capable of effectively managing them, and have proved to be of great interest to the general hospital psychiatric community as a whole. It is unclear, however, to what degree the models of care on these units are applicable to units with a heterogeneous patient population. Despite the important position of general hospital inpatient psychiatry in patient care and training, it remains a central and often unappreciated fact that it must serve many masters. As Greenhill noted in his comprehensive 1979 review, general hospital inpatient psychiatry faces Janus-like in two directions: on the one side, the community with its need for local treatment and close cooperation with publicly-based resources, and on the other, the general hospital itself with its expectation of medically sophisticated and timely care for patients who require psychiatric treatment during hospitalization [5]. The burden of these competing roles is often complicated by the small size of general hospital psychiatric units in individual hospitals. A minority of general hospitals have more than one inpatient unit that would allow specialization of treatment and organization. The average general hospital, however, has but a single unit and, as 79 ISSN 0163.8343!91!$3.50
P. Summergrad
such, it must operate more like a one-room schoolhouse, treating a highly heterogeneous patient population, rather than acting as a specialty service. It is not surprising that the literature on general hospital inpatient psychiatry is peppered with articles describing how units modify their activities as they are forced to care for a wider range of patients, whether they are geriatric, medically ill, or former residents of state hospitals [8,9]. Unit organizations and treatment structures that may work well for one group on such a mixed general hospital unit may unfortunately not be helpful for other patients who simultaneously need its care. These conditions of general hospital inpatient psychiatry are not new. Tensions over the proper role of general hospital inpatient psychiatry can be found in the literature of the 193Os, as well as more recent discussions [l]. As in the 193Os, other forces are bringing new pressures to bear on general hospital inpatient psychiatry, ones which offer both opportunities for change and growth, as well as the inevitable difficulties inherent in such a process. What are these new forces? Chief among them are economic. It comes as no surprise to anyone who has so much as wandered by a general hospital psychiatric unit these days that patients are being treated more rapidly than in previous years. Even in teaching hospitals, the average length of stay in many settings has dropped from 40 days only a few years ago to nearly 2 weeks at present. Not only are patient stays briefer, patients are often more ill at admission. Screening requirements for insurance companies and managed care contracts, including those with HMOs, have served to make criteria for hospitalization more stringent. It is not uncommon to hear war stories of patients denied admission to the hospital because they were deemed not overtly suicidal by their third-party payors. Moreover, the frequent telephone calls of insurance companies to attending staff during the course of hospitalization often work in subtle and not so subtle ways to force patients out of the hospital-albeit improved, but sicker than their psychiatrists might like. General hospital administrators, often with little interest in inpatient psychiatry because of the relatively low hospital reimbursement for such care, further increase the pressures to keep beds full. As more hospitals decrease length of stay, excess bed capacity is “created.” Given the limited pool of psychiatric patients with insurance to fill the beds, the “market” then forces the length of stay to lower as units compete for 80
managed care contracts. Sicker patients, less well known to staff, are admitted to units often poorly designed for the care of the medically or severely mentally ill, further increasing staff tension and anxiety. As a consequence, these changes place new pressures on directors of inpatient services to teach (and often learn) short-term models of care while they attempt to maintain staff morale. In addition to the increased acuity of patients and competition to keep beds filled, general hospital inpatient units often must compete with larger private psychiatric hospitals for patients and for attention within the general hospital itself. Within the general hospital, the particular needs and regulatory environment of the inpatient psychiatric unit are often little understood by hospital administrators, despite the fact that DRG-exempt inpatient units are required, as a condition of their exemption, to have discrete admission screening procedures and keep records of such activities distinct from the rest of the general hospital. There is little incentive for such hospitals to retool any aspect of their administrative structure to meet the needs of a small and, from the hospital’s viewpoint, fiscally insignificant part of the institution. Despite the requirements for interdisciplinary work on general hospital units, lines of authority over unit staff may remain fractured, increasing staff conflict and inefficiency. The nursing and social work staff may report to senior hospital administrators and not to the inpatient unit director. Such an arrangement, although workable, may require extra effort to maintain good working relationships while attempting to implement potentially difficult changes. Although general hospital units may have certain advantages over private psychiatric hospitals, especially with regard to more generous use of insurance for inpatient care and their ability to care for medically ill patients, there may be areas of disadvantages. Private psychiatric hospitals are primarily in the business of providing inpatient psychiatric care. As such, they have an institutional imperative to modify clinical or administrative service structures so as to increase admission and decrease length of stay. Private psychiatric hospitals are likely to find it easier to provide specialty services as well as a range of partial hospitalization alternatives, potentially increasing their ability to enter into contracts with HMOs and others. Additionally, they may have an economy of scale, which provides an advantage. In the general hospital, marketing and admission services are likely
Editorial
to be geared to the needs of medical and surgical services, leaving the general hospital psychiatric unit the burden of bootstrapping such functions. For the private psychiatric hospital, these represent activities that the institution as a whole must undertake and that can be organized, perhaps less expensively, around the particular needs of psychiatric patients. Pressures for change have also affected the inpatient services in teaching general hospitals. New training guidelines in New York and proposed similar changes in other states have mandated increased attending availability to and supervision of resident staff. Third-party payors have, likewise, demanded greater accountability from attending psychiatrists on teaching units, especially regarding direct patient services and documentation. Additionally, medicolegal and liability concerns have affected attending behavior. Threats of malpractice actions, when less than state-of-the-art psychopharmacologic regimens are employed, may necessitate senior psychiatric staff involvement [lo]. These pressures have had the salutory effect of bringing attending psychiatric staff from groups or team meetings to the bedside of patients. The size of attending staff is being increased on many teaching units and daily walk-rounds with attending, resident, and other staff are not uncommon occurrences. These changes in the level of attending involvement as well as in the increased acuity of patients and shortened length of stay may be reshaping resident training. Contributing to this new climate for inpatient training as well may be the greater focus during inpatient hospitalization on medical, neuroimaging, diagnostic and psychopharmacologic aspects of care, tendencies that are likely to accelerate with advances in the neurosciences. These developments may be making training experiences less experiential and more observational. Additionally, they may diminish the chance for residents to utilize their longitudinal inpatient experiences for early training in psychodynamics [ll]. Despite the fact that inpatient training is mandated to occur for at least 9 months of a resident’s training, there are few, if any, curricula or defined goals for inpatient experiences. Leibenluft et al. have alluded to the impact that these changes in inpatient psychiatry are having on the academic performance and longevity of the term of inpatient directors. The relatively rapid turnover of general hospital inpatient directors brings diminished stability to these complex ser-
vices at a time of increasing change, and contributes to the relative dearth of senior academic figures directing general hospital inpatient services. It also contributes to the limited research done in general hospital inpatient psychiatry as well as the lack of representation of general hospital inpatient psychiatry among national academic and subspecialty organizations [12]. This low academic profile may be of greater significance if proposed specialization in consultation-liaison and other areas of psychiatry becomes a reality. The article by Rosenbaum in this issue of General Hospital Psychiatry, entitled “Violence in Psychiatric Wards: Role of the Lax Milieu,” also helps us remember that these problems are far from academic alone, but also have important clinical consequences [13]. Although the cause of violence in inpatient settings may be a matter for some dispute, Rosenbaum reminds us that organizational structures in inpatient psychiatry are of great importance in reducing the regressive side effects of hospitalization. Given the many rapid changes that are occurring in general hospital inpatient psychiatry, new circumstances require leadership, attention, and research. As we face the 199Os, we can anticipate continuing changes on general hospital inpatient services that will require local and national responses. It seems unlikely that pressures to decrease length of stay, admit sicker patients, or respond to the competition inherent in managed care will diminish. In some locations, general hospital inpatient services may be asked to assume more responsibilities for state hospital care. It is likely that these pressures will require an integrated system of care that may, with local variations, include private psychiatric hospitals, state hospitals, and outpatient and partial hospital functions. General hospital inpatient services may have to offer involuntary, locked care or other specialized psychiatric units, perhaps employing much of what has been developed on medical-psychiatric units. The lines between medical-psychiatric units and heterogenous or mixed general hospital units are already blurring, and, with increased emphasis on attending physician involvement and daily walk-rounds, these lines may blur further. Developments in the neurosciences are likely to further emphasize the central medical-psychiatric role of physician leadership on them. These changes will need to be reflected in appropriate administrative, political, academic, and organizational developments. Administratively,
81
I’. Summergrad
general hospital inpatient psychiatry will need to find new structures within the general hospital to allow clearer lines of authority on units and more effective access to central administrative capacities in admissions, quality assurance, discharge planning, and marketing. Politically, increased organizational activities on local and national levels will be needed to help define the specialty capabilities of general hospital inpatient psychiatry and its role in the overall provision of psychiatric services, and to continue adequate reimbursement for services. These activities may require greater organizational support, both from groups such as the American Association of General Hospital Psychiatrists and other national psychiatric organizations, especially around issues of administration, models of care, research, academic advancement, and training. At present, despite the fact that most inpatient psychiatric admissions occur in general hospitals, there is no organization, such as the National Association of Private Psychiatric Hospitals, focused on these issues at the national or state-wide level. Academically, attention must be paid to the impact of these changes on the training of psychiatric residents, as well as the goals for such training. Research in the efficacy, outcome, and demographics of general hospital inpatient care is desperately needed so that we can learn whom we treat and how we can treat them more effectively 1141. We also need to foster the development of senior general hospital inpatient psychiatrists, capable of providing ongoing leadership for the field as a whole. The place of general hospital inpatient psychiatry within the general hospital psychiatric community needs consideration as well. Is it truly in the best interest of general hospital psychiatry as a whole to formalize a subspecialty in consultationliaison psychiatry when general hospital inpatient psychiatry shares a clinical, intellectual, and institutional base with it in the general hospital? A number of individuals involved in the development of medical-psychiatric units have been providing national leadership in the emergence of a broad-based medical psychiatry [ 151. Will excessive subspecialization fracture what could be a unified and more powerful identity as medical and general hospital psychiatrists? The coming decade provides great opportunities for general hospital inpatient psychiatry in training, models of clinical care, and medical-
82
psychiatric treatment and research. Advances in neurobiology and psychopharmacology as well as the broadening clinical population of general hospital inpatient psychiatry make it the setting where the most sophisticated and comprehensive psychiatric care can and should take place. Attention to these opportunities and dilemmas is now crucial for the further development and viability, not just of general hospital inpatient psychiatry, but of general hospital psychiatry as a whole.
References 1. Summergrad
2.
3. 4.
5. 6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
I’, Hackett TP. Alan Gregg and the rise of general hospital psychiatry; Gen Hosp Psychiatry 9:439-445, 1987 Kiesler CA, Sibulkin AE: Episodic rate of mental hospitalization: stable or increasing? Am J Psychiatry 14144-48, 1984 Schulberg HC: Psychiatric units in general hospitals: bone or bane? Am J Psychiatry 120:30-35, 1963 Bachrach LL: General hospital psychiatry: overview from a sociological perspective. Am J Psychiatry 138:879-887, 1981 Greenhill MH: Psychiatric units in general hospitals: Hosp Community Psychiatry 30~169-182, 1979 Hackett TP: The psychiatrist: in the mainstream or on the banks of medicine. Am J Psychiatry 134:432434‘ 1977 Stoudemire A, Fogel BS: Organization and development of combined medical-psychiatric units: part 1. psychosomatics. 27:341-345, 1986 Schoonover SC, Bassuk EL: Deinstitutionization and the private general hospital inpatient unit. Implications for clinical care. Hosp Community Psychiatry 34:135-139, 1983 Billig N, Leibenluft E: Special considerations in integrating elderly patients into a general hospital unit. Hosp Community Psychiatry 38:277-281, 1987 KIerman GL: The patient’s right to effective treatment: implications of Osheroff v. Chestnut Lodge. Am J Psychiatry 147:409-418 1990 Gorton G, Mechanick S: Inpatient training: experiential or apprenticeship?: presentation, annual meeting, Association for Academic Psychiatry; Seattle, WA., March, 1990 Leibenluft E, Summergrad I’, Tasman A: The academic dilemma of the inpatient unit director. Am J Psychiatry 146:73-76, 1988 Rosenbaum M: Violence in psychiatric wards-role of the Lax Milieu. Gen Hosp Psychiatry 13:00-000, 1991 Olfson M: Treatment of depressed patients in general hospitals with scatter beds, cluster beds and psychiatric units. Hosp Community Psychiatry 41:1106-1111, 1990 Stoudemire A, Fogel B: Principles of Medical Psychiatry. Orlando: Grune and Stratton, Inc., 1987: PPI 719
General Hospital Inpatient Psychiatry in the 1990s: Problems and Possibilities Paul Summergrad,
M.D.”
Inpatient psychiatry in the general hospital occupies an unusual position. The development of general hospital inpatient services in the 1930s and their subsequent growth have been important for the clinical, academic and economic success of general hospital psychiatry. Whereas consultation-liaison activities have provided an important service to the general hospital, especially as a point of direct contact with the medical staff, inpatient services have been significant in other ways. Overcoming skepticism about the capacity of the general hospital to care for psychiatric patients at all, general hospital inpatient units have helped to enlarge the scope of psychiatric inpatient care, have served as a location for early research in biologic psychiatry, and have been a major source of income for many departments of psychiatry [l]. Indeed, general hospitals treat both in scatter beds and on discrete general hospital units approximately 60% of all patients hospitalized in the United States with a primary psychiatric diagnosis [2]. General hospital inpatient psychiatry has often been buffeted by theoretical fashions and trends, but these have affected psychiatry as a whole. For example, the growth of general hospital inpatient psychiatry was stimulated by the post-World War II success of the then predominant psychodynamic model. Then, in the 1950s and 196Os, milieu models of inpatient psychiatric care were imported from state hospitals to general hospitals. The wholesale and often uncritical entry of these models from settings where they appropriately attempted to address problems of custodial care to general hospitals occurred with seemingly little awareness of the *Director, eral Hospital; ical School.
Inpatient Assistant
Psychiatric Professor
Service, Massachusetts of Psychiatry, Harvard
Gown/ Hosprfai Psydliafry 13, 79-82, IYYI cj 1991 Elsevier S&nce Publishing Co., Inc. hS.‘rA\,rnurottheAmericds,Ne~‘York,NY 10010
GenMed-
different culture and needs of the latter setting. Others have seen general hospital psychiatry units as the successor institution to the state hospital, suggesting that care of the chronically mentally ill should be a prime responsibility of such units. Again, these suggestions have often been made with little cognizance of how these goals might fit into the patterns of care and organization of such units [3,4,5]. Recently, as part of the much needed remedicalization of psychiatry, medical-psychiatric units have been created [6,7]. These units emphasize bedside rounding, physician expertise, and management of medically complex and psychiatrically ill patients in the only setting capable of effectively managing them, and have proved to be of great interest to the general hospital psychiatric community as a whole. It is unclear, however, to what degree the models of care on these units are applicable to units with a heterogeneous patient population. Despite the important position of general hospital inpatient psychiatry in patient care and training, it remains a central and often unappreciated fact that it must serve many masters. As Greenhill noted in his comprehensive 1979 review, general hospital inpatient psychiatry faces Janus-like in two directions: on the one side, the community with its need for local treatment and close cooperation with publicly-based resources, and on the other, the general hospital itself with its expectation of medically sophisticated and timely care for patients who require psychiatric treatment during hospitalization [5]. The burden of these competing roles is often complicated by the small size of general hospital psychiatric units in individual hospitals. A minority of general hospitals have more than one inpatient unit that would allow specialization of treatment and organization. The average general hospital, however, has but a single unit and, as 79 ISSN 0163.8343!91!$3.50
P. Summergrad
such, it must operate more like a one-room schoolhouse, treating a highly heterogeneous patient population, rather than acting as a specialty service. It is not surprising that the literature on general hospital inpatient psychiatry is peppered with articles describing how units modify their activities as they are forced to care for a wider range of patients, whether they are geriatric, medically ill, or former residents of state hospitals [8,9]. Unit organizations and treatment structures that may work well for one group on such a mixed general hospital unit may unfortunately not be helpful for other patients who simultaneously need its care. These conditions of general hospital inpatient psychiatry are not new. Tensions over the proper role of general hospital inpatient psychiatry can be found in the literature of the 193Os, as well as more recent discussions [l]. As in the 193Os, other forces are bringing new pressures to bear on general hospital inpatient psychiatry, ones which offer both opportunities for change and growth, as well as the inevitable difficulties inherent in such a process. What are these new forces? Chief among them are economic. It comes as no surprise to anyone who has so much as wandered by a general hospital psychiatric unit these days that patients are being treated more rapidly than in previous years. Even in teaching hospitals, the average length of stay in many settings has dropped from 40 days only a few years ago to nearly 2 weeks at present. Not only are patient stays briefer, patients are often more ill at admission. Screening requirements for insurance companies and managed care contracts, including those with HMOs, have served to make criteria for hospitalization more stringent. It is not uncommon to hear war stories of patients denied admission to the hospital because they were deemed not overtly suicidal by their third-party payors. Moreover, the frequent telephone calls of insurance companies to attending staff during the course of hospitalization often work in subtle and not so subtle ways to force patients out of the hospital-albeit improved, but sicker than their psychiatrists might like. General hospital administrators, often with little interest in inpatient psychiatry because of the relatively low hospital reimbursement for such care, further increase the pressures to keep beds full. As more hospitals decrease length of stay, excess bed capacity is “created.” Given the limited pool of psychiatric patients with insurance to fill the beds, the “market” then forces the length of stay to lower as units compete for 80
managed care contracts. Sicker patients, less well known to staff, are admitted to units often poorly designed for the care of the medically or severely mentally ill, further increasing staff tension and anxiety. As a consequence, these changes place new pressures on directors of inpatient services to teach (and often learn) short-term models of care while they attempt to maintain staff morale. In addition to the increased acuity of patients and competition to keep beds filled, general hospital inpatient units often must compete with larger private psychiatric hospitals for patients and for attention within the general hospital itself. Within the general hospital, the particular needs and regulatory environment of the inpatient psychiatric unit are often little understood by hospital administrators, despite the fact that DRG-exempt inpatient units are required, as a condition of their exemption, to have discrete admission screening procedures and keep records of such activities distinct from the rest of the general hospital. There is little incentive for such hospitals to retool any aspect of their administrative structure to meet the needs of a small and, from the hospital’s viewpoint, fiscally insignificant part of the institution. Despite the requirements for interdisciplinary work on general hospital units, lines of authority over unit staff may remain fractured, increasing staff conflict and inefficiency. The nursing and social work staff may report to senior hospital administrators and not to the inpatient unit director. Such an arrangement, although workable, may require extra effort to maintain good working relationships while attempting to implement potentially difficult changes. Although general hospital units may have certain advantages over private psychiatric hospitals, especially with regard to more generous use of insurance for inpatient care and their ability to care for medically ill patients, there may be areas of disadvantages. Private psychiatric hospitals are primarily in the business of providing inpatient psychiatric care. As such, they have an institutional imperative to modify clinical or administrative service structures so as to increase admission and decrease length of stay. Private psychiatric hospitals are likely to find it easier to provide specialty services as well as a range of partial hospitalization alternatives, potentially increasing their ability to enter into contracts with HMOs and others. Additionally, they may have an economy of scale, which provides an advantage. In the general hospital, marketing and admission services are likely
Editorial
to be geared to the needs of medical and surgical services, leaving the general hospital psychiatric unit the burden of bootstrapping such functions. For the private psychiatric hospital, these represent activities that the institution as a whole must undertake and that can be organized, perhaps less expensively, around the particular needs of psychiatric patients. Pressures for change have also affected the inpatient services in teaching general hospitals. New training guidelines in New York and proposed similar changes in other states have mandated increased attending availability to and supervision of resident staff. Third-party payors have, likewise, demanded greater accountability from attending psychiatrists on teaching units, especially regarding direct patient services and documentation. Additionally, medicolegal and liability concerns have affected attending behavior. Threats of malpractice actions, when less than state-of-the-art psychopharmacologic regimens are employed, may necessitate senior psychiatric staff involvement [lo]. These pressures have had the salutory effect of bringing attending psychiatric staff from groups or team meetings to the bedside of patients. The size of attending staff is being increased on many teaching units and daily walk-rounds with attending, resident, and other staff are not uncommon occurrences. These changes in the level of attending involvement as well as in the increased acuity of patients and shortened length of stay may be reshaping resident training. Contributing to this new climate for inpatient training as well may be the greater focus during inpatient hospitalization on medical, neuroimaging, diagnostic and psychopharmacologic aspects of care, tendencies that are likely to accelerate with advances in the neurosciences. These developments may be making training experiences less experiential and more observational. Additionally, they may diminish the chance for residents to utilize their longitudinal inpatient experiences for early training in psychodynamics [ll]. Despite the fact that inpatient training is mandated to occur for at least 9 months of a resident’s training, there are few, if any, curricula or defined goals for inpatient experiences. Leibenluft et al. have alluded to the impact that these changes in inpatient psychiatry are having on the academic performance and longevity of the term of inpatient directors. The relatively rapid turnover of general hospital inpatient directors brings diminished stability to these complex ser-
vices at a time of increasing change, and contributes to the relative dearth of senior academic figures directing general hospital inpatient services. It also contributes to the limited research done in general hospital inpatient psychiatry as well as the lack of representation of general hospital inpatient psychiatry among national academic and subspecialty organizations [12]. This low academic profile may be of greater significance if proposed specialization in consultation-liaison and other areas of psychiatry becomes a reality. The article by Rosenbaum in this issue of General Hospital Psychiatry, entitled “Violence in Psychiatric Wards: Role of the Lax Milieu,” also helps us remember that these problems are far from academic alone, but also have important clinical consequences [13]. Although the cause of violence in inpatient settings may be a matter for some dispute, Rosenbaum reminds us that organizational structures in inpatient psychiatry are of great importance in reducing the regressive side effects of hospitalization. Given the many rapid changes that are occurring in general hospital inpatient psychiatry, new circumstances require leadership, attention, and research. As we face the 199Os, we can anticipate continuing changes on general hospital inpatient services that will require local and national responses. It seems unlikely that pressures to decrease length of stay, admit sicker patients, or respond to the competition inherent in managed care will diminish. In some locations, general hospital inpatient services may be asked to assume more responsibilities for state hospital care. It is likely that these pressures will require an integrated system of care that may, with local variations, include private psychiatric hospitals, state hospitals, and outpatient and partial hospital functions. General hospital inpatient services may have to offer involuntary, locked care or other specialized psychiatric units, perhaps employing much of what has been developed on medical-psychiatric units. The lines between medical-psychiatric units and heterogenous or mixed general hospital units are already blurring, and, with increased emphasis on attending physician involvement and daily walk-rounds, these lines may blur further. Developments in the neurosciences are likely to further emphasize the central medical-psychiatric role of physician leadership on them. These changes will need to be reflected in appropriate administrative, political, academic, and organizational developments. Administratively,
81
I’. Summergrad
general hospital inpatient psychiatry will need to find new structures within the general hospital to allow clearer lines of authority on units and more effective access to central administrative capacities in admissions, quality assurance, discharge planning, and marketing. Politically, increased organizational activities on local and national levels will be needed to help define the specialty capabilities of general hospital inpatient psychiatry and its role in the overall provision of psychiatric services, and to continue adequate reimbursement for services. These activities may require greater organizational support, both from groups such as the American Association of General Hospital Psychiatrists and other national psychiatric organizations, especially around issues of administration, models of care, research, academic advancement, and training. At present, despite the fact that most inpatient psychiatric admissions occur in general hospitals, there is no organization, such as the National Association of Private Psychiatric Hospitals, focused on these issues at the national or state-wide level. Academically, attention must be paid to the impact of these changes on the training of psychiatric residents, as well as the goals for such training. Research in the efficacy, outcome, and demographics of general hospital inpatient care is desperately needed so that we can learn whom we treat and how we can treat them more effectively 1141. We also need to foster the development of senior general hospital inpatient psychiatrists, capable of providing ongoing leadership for the field as a whole. The place of general hospital inpatient psychiatry within the general hospital psychiatric community needs consideration as well. Is it truly in the best interest of general hospital psychiatry as a whole to formalize a subspecialty in consultationliaison psychiatry when general hospital inpatient psychiatry shares a clinical, intellectual, and institutional base with it in the general hospital? A number of individuals involved in the development of medical-psychiatric units have been providing national leadership in the emergence of a broad-based medical psychiatry [ 151. Will excessive subspecialization fracture what could be a unified and more powerful identity as medical and general hospital psychiatrists? The coming decade provides great opportunities for general hospital inpatient psychiatry in training, models of clinical care, and medical-
82
psychiatric treatment and research. Advances in neurobiology and psychopharmacology as well as the broadening clinical population of general hospital inpatient psychiatry make it the setting where the most sophisticated and comprehensive psychiatric care can and should take place. Attention to these opportunities and dilemmas is now crucial for the further development and viability, not just of general hospital inpatient psychiatry, but of general hospital psychiatry as a whole.
References 1. Summergrad
2.
3. 4.
5. 6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
I’, Hackett TP. Alan Gregg and the rise of general hospital psychiatry; Gen Hosp Psychiatry 9:439-445, 1987 Kiesler CA, Sibulkin AE: Episodic rate of mental hospitalization: stable or increasing? Am J Psychiatry 14144-48, 1984 Schulberg HC: Psychiatric units in general hospitals: bone or bane? Am J Psychiatry 120:30-35, 1963 Bachrach LL: General hospital psychiatry: overview from a sociological perspective. Am J Psychiatry 138:879-887, 1981 Greenhill MH: Psychiatric units in general hospitals: Hosp Community Psychiatry 30~169-182, 1979 Hackett TP: The psychiatrist: in the mainstream or on the banks of medicine. Am J Psychiatry 134:432434‘ 1977 Stoudemire A, Fogel BS: Organization and development of combined medical-psychiatric units: part 1. psychosomatics. 27:341-345, 1986 Schoonover SC, Bassuk EL: Deinstitutionization and the private general hospital inpatient unit. Implications for clinical care. Hosp Community Psychiatry 34:135-139, 1983 Billig N, Leibenluft E: Special considerations in integrating elderly patients into a general hospital unit. Hosp Community Psychiatry 38:277-281, 1987 KIerman GL: The patient’s right to effective treatment: implications of Osheroff v. Chestnut Lodge. Am J Psychiatry 147:409-418 1990 Gorton G, Mechanick S: Inpatient training: experiential or apprenticeship?: presentation, annual meeting, Association for Academic Psychiatry; Seattle, WA., March, 1990 Leibenluft E, Summergrad I’, Tasman A: The academic dilemma of the inpatient unit director. Am J Psychiatry 146:73-76, 1988 Rosenbaum M: Violence in psychiatric wards-role of the Lax Milieu. Gen Hosp Psychiatry 13:00-000, 1991 Olfson M: Treatment of depressed patients in general hospitals with scatter beds, cluster beds and psychiatric units. Hosp Community Psychiatry 41:1106-1111, 1990 Stoudemire A, Fogel B: Principles of Medical Psychiatry. Orlando: Grune and Stratton, Inc., 1987: PPI 719
