Role of super-specialities in psychiatry.

Sir,

Thanks to Manjunatha et al.[1] for bringing out a debatable but important topic of emerging super-specialties in psychiatry. There are two important issues to consider in this matter.

The first is an ancient Indian wisdom that “only the whole is perfect and the part imperfect.” This is in a sense: (i) As sage Vashishtha instructs prince Rama, “All things are different functional aspects of the whole.”[2] (ii) as the wise Vidura advices King Dritharashtra, “those that are competent in the general (read holistic) principles of work, though not in particular kind of work, are indeed learned and wise. Because, particular kinds of work are ever subsidiary to the whole.”[3] From this point of view, it is very difficult for an average super-specialist to assess and manage a patient in a holistically effective manner. Almost every one of us is familiar with an occasional scenario: A patient consults a super-specialist and gets referred across the entire band-width of super-specialists. More than three decades ago, a cartoon in “Punch” magazine carried the same message showing a group of perplexed specialists surrounding a patient, and one of them suggesting: “We are all specialists. Let us consult a general practitioner…” In the general medical profession, the emerging wisdom is that the back-bone of a nation's health is the well-trained family physician. In psychiatry, the family physician's equivalent is the “general (adult) psychiatrist.”

The second is the famous Gaussian distribution of all natural phenomena, which also includes our psychiatric patient population. At one extreme, will be that small proportion of patients who can heal themselves even if slowly. Under the large central bulge will be those majority who can get well with the help of varying degrees of expertise, like that of a “general psychiatrist.” At the other extreme will be the small proportion of patients who are relatively more resistant to conventional management strategies requiring more specialized expertise.

It is obvious that the ideal setting will be something like this: (i) The family physician, as a back-bone of health services will refer those psychiatric patients beyond his range of expertise to psychiatric services. (ii) The “general psychiatrist,” as a back-bone of psychiatric services will manage a large majority of them. He will refer the small proportion of difficult to manage patients to respective super-specialists. (iii) These super-specialists in the field of psychiatry will be required to pursue “frontier research” and to train the “general psychiatrists.”