Rediscovering general psychiatry: creation of an academic division.
ABSTRACT To describe the rationale, origins, and goals of a newly created academic division of general psychiatry within a university setting.
Literature review, observation, and description.
Within 2 years of its inception, the General Psychiatry Division of the University of Toronto has begun to realize some of its goals and further elucidate specific objectives.
In an era of increasing academic subspecialization, the preservation of core skills in psychiatry and the recognition of the continuing public need for psychiatric generalists must be enshrined within academic training programs.
- Psychiatric Bulletin 01/1995; 19(2):121-122.
Rediscovering General Psychiatry: Creation of
David?S Goldbloom,?MD, FRCPC1, Robert A?Buckingham, MD, FRCPC2, Peter Voore, MD, FRCPC3
within a university setting.
Method: Literature review, observation, and description.
Results: Within 2 years of its inception, the General Psychiatry Division of the University of Toronto has begun
to realize some of its goals and further elucidate specific objectives.
Conclusions: In anera of increasing academic subspecialization,the preservation of core skillsin psychiatry and
the recognition of the continuing public need for psychiatric generalists must be enshrined within academic
(Can J Psychiatry 1997;42:58–62)
Key Words: psychiatry, education, residency, generalist
pants was described as arguing that “generalpsychiatristsare
the specialists do not want to treat. There is no objective
evidence that specialization in psychiatry is of benefit. Psy-
chiatry is not highly technical so there is little need for
specialization and if it occurs it should not be solely on the
basis of one major research project” (1; p 121). Another
speaker commented that “one cannot become a subspecialist
without being a good general psychiatristfirst.It isa paradox
to erect a fence around general psychiatry to save it from its
n 1994, a forum held at the Winter Meeting of the Royal
College of Psychiatrists in England centred around the
While this forum did not generate specific solutions, the fact
that it occurred suggests a tension within psychiatric training
that crosses national boundaries.
Similarly, in the United States there has recently been a
call to redefine the general psychiatrist. Beigel and Santiago
(2) call for a new set of values for general psychiatrists that
increase emphasis on multidisciplinary teamwork; complex
cases which traverse boundaries between medicine and psy-
chology; the severely mentally ill; and the role and delivery
of psychotherapy, “some of which can be effectively deliv-
ered by nonmedical mental health professionals” (2; p 770).
In order to achieve this, the authors suggested curricular
reform that included a wider range of training settings such
as community support programs and family practice clinics;
more formal training in multidisciplinary teamwork and the
nature of leadership; more awareness of service use patterns
and implications as well as fundamentals of quality assur-
comfort with, confidence in, and commitment to working
with chronically mentally ill patients; and retaining psycho-
therapy asa coreskillbut placing moreemphasisona variety
of short-term interventions and balancing it with skills such
as crisis intervention, complex diagnostic assessment, phar-
macotherapy, and consultation to primary care providers.
Over the last 3 decades, the Department of Psychiatry at
the University of Toronto has grown into the largest such
department and residency training program in Canada and
one of the largest in North America.It currently includes 500
Manuscript received March 1996, revised August 1996.
Portions of this manuscript were originally presented as part of the Robin
Hunter Memorial Lecture by the senior author in June 1993.
1Vice President Medical Affairs and Chief of Staff, Clarke Institute of
Psychiatry; Associate Professor and Head, General Psychiatry Division,
University of Toronto, Toronto, Ontario.
2Clinical Director, Department of Psychiatry, The Toronto Hospital; Asso-
ciate Professor and Deputy Head, General Psychiatry Division, University
of Toronto, Toronto, Ontario.
3Associate Head, General Psychiatry Division, Clarke Institute of Psychia-
try; Assistant Professor, University of Toronto, Toronto, Ontario.
try, 250 College Street, Toronto, ON M5T 1R8
Can?J?Psychiatry, Vol 42, February 1997
full- and part-time faculty members and provides training for
120 psychiatry residents, 35 fellows, and many additional
allied health professions students. The development of such
a complex department, spread over 17 hospitals and addi-
tional clinical and academic facilities, has been accompanied
by the evolution of areas of focal academic interest into a
matrix that includes the following subspecialty divisions and
programs: child psychiatry; geriatric psychiatry; women’s
mental health; forensic psychiatry; psychosomatic medicine;
culture, community, and health; mental health systems deliv-
ery; psychotherapy; mood disorders; schizophrenia research;
drugs and alcohol; and psychopharmacology. While there is
inevitable overlap between these categories from clinical,
research, and training perspectives, their separation has been
a helpful academic exercise in scholarly development, as
reflected by recruitment of a critical mass of colleagues,
research grants and publications, innovative clinical pro-
gramming, and new subspecialty training opportunities.
The size and resources of this university department have
clearly facilitated its expansion into subspecialty areas in
ways that parallel the developments in medicine, pediatrics,
and surgery years earlier. With such subdivision of a spe-
cialty, however, comes the risk of losing the core of the
field—and losing sight of community needs. A further risk is
problem may be less prominent for smaller training centres
where opportunities for subspecialty training are less
The impetus to develop a general psychiatry division
within this complex matrix evolved from both internal and
external needs and pressures. In 1992, the Committee on
Psychiatric Education, a national body comprised of all
try and elected residents, created a set of training objectives
for adult general psychiatry. These objectives far exceeded
the delineated expectations of the Royal College of Physi-
of general hospital psychiatry training in residency, in that
they included specific objectives in the areas of knowledge,
skills, and attitudes. That same year, an internal document
try entitled “Fulfilling Our Public Trust” examined ways in
dation of this report was the creation of a general psychiatry
division with clear objectives for training both junior and
senior residents as well as a commitment to continuing medi-
ince. Within 6 months of that report, a general psychiatry
division was established, a division head selected (DG), and
the task of developing an academic program initiated.
Thus the currents of change fomented with regard to
general psychiatry can be seen as stemming from 2 principal
sources: increasing subspecialization within the field and
services. A third factor that is driving the process of transfor-
mation is the perception and reality of general psychiatric
practice. In 1992, a researcher reviewed perceptions about
psychiatrists between 1941 and 1990 as reflected by their
representation in magazine cartoons (3). Interestingly,
has published the results in peer-reviewed journals. In the
1992 study, 404 cartoons were reviewed and clustered by
decade. The result was clear; there has been no appreciable
It raises the question of whether it is the perception or the
reality that is static. A 1991 survey of the graduates of
psychiatry residency training programs between 1980 and
1989 in Ontario (Garfinkel and Voineskos, personal commu-
nication) revealed graduates of the University of Toronto
program to be the most likely to practice a stereotype of
cosmopolitan psychiatry. They were more likely than gradu-
ates of other programs to work in a private office seeing
individuals with personality disorder in psychotherapy; they
were correspondingly less likely to provide indirect patient
care, work in provincial psychiatric hospitals, work with
inpatients, the elderly, or families, prescribe antidepressants,
anxiolytics, or antipsychotics, and see new patients; and they
carried smaller case loads, presumably for more intensive
individual treatment. As pointed out recently by Dr William
McCormick, past president of the Canadian Psychiatric As-
sociation, while the total number of psychiatrists practising
in the province of Ontario well exceeds the numbers recom-
mended by both governmental and professional guidelines,
there remain over 100 vacancies for psychiatrists in general
hospitals across the province (4). This problem relates not
only to geographic maldistribution but also to the issue of
practice patterns. The general psychiatrist had become pri-
marily a psychotherapist, and the balance between direct
patient care and the consultant role of a specialistwas askew.
Before one charts the course for general psychiatry, it is
instructive to examine developments in general internal
medicine, general pediatrics, and general surgery. A sympo-
was convened at the annual meeting of the RCPSC in 1993
(5). It followed 2 decades of evolving importance of internal
medicine subspecialties and led to the following definition of
the roles of the general internist: patient-centred clinician
often dealing with either undifferentiated or multisystem
illness; teacher at all levels of clinical skills and application
of evidence-based care; researcher in such areas as accuracy
and cost-effectiveness of diagnostic evaluations and
February 1997Rediscovering General Psychiatry59
macology, medical informatics, and medical education; ad-
ministrator in hospitals, university departments,
communities, and professional associations.
Two types of generalinternistswere defined: community-
academic divisions of general internal medicine in all
opportunities for community-practice exposure for trainees,
and a strategy for continuing medical education. A survey of
practitioners of general internal medicine in Ontario (6)
provided empirical data on the nature of their professional
activities and their perceptions of how their professional
satisfaction might be improved. Apart from specific sugges-
tions for curriculum reform and fee schedule reform, the
survey revealedthatpositiveinteractionsbetween physicians
Association of Medical Colleges has called for a bolstering
of general internal medicine—but he defines the general
the diagnosis of the problems for general internal medicine
are different in the United States—particularlywith regard to
market forces and third-party payment—the cures have ele-
a more prominent role for community-based exposure to
role for general internists within the university hierarchy; a
fellowships; and a decrease in academic prejudice toward
primary care careers. At the same time, Petersdorf rails
his Canadian colleagues and in contrast to trends in psychia-
try, where each emerging subspecialty seems to wish for its
rings! Finally, the Federated Council for Internal Medicine
health services research, clinical epidemiology, and educa-
tional sciences to give them the “credence and academic
prestige . . . now extended to research in the basic medical
sciences” (8; p 779).
In pediatrics, the development of academic general pedi-
sity pediatrics programs for 10 years (9). This mammoth
effort was described by Robert Haggerty as “an ambitious
attempt to revive the academic general pediatrician,” whom
he described as “an endangered species” (9; p 413). He
observed that in the past, academic pediatricians had trained
cialty interests, but current academic faculty are clinically
that “patients complain of difficulty in knowing which sub-
address common or multisystem problems as often as seems
desirable” (9; p 413). He defined 4 principal roles for the
academic general pediatrician: expert clinician (for which he
behavioural sciences, and evidence-based medicine; teacher
at all levels including continuing education for practitioners;
and leader in advocacy for children in the community and for
social change. Another author has argued for the 7 functions
of a general pediatrics program within an academic depart-
ment (10): teaching at every level; developmental and
behavioural pediatrics; preventive pediatrics and epidemiol-
ogy; community services and child advocacy; administrative
leadership; primary and secondary care for children with
complex and often chronic problems; and research.
In surgery, a recent survey of the 16 Canadian university-
based training program directors alludes to a “rural health-
care crisis” with regard to the paucity of available newly
trained general surgeons and the advancing age of those
currently in practice (11). Seventy-five percent of those sur-
veyed saw a continuing need for training of general surgeons
and a need for the evolution of training guidelines. While
community surgery rotations were available at 15 of the 16
programs, only 20% to 25% of trainees took part in such
experiences during their residencies,despite the value placed
on such rotations by the RCPSC. The survey authors argued
for mandatory communitysurgeryrotationsduring residency
and optional general surgery fellowships, as well as a revisi-
tation of the range of subspecialty exposure needed for com-
munity-based general surgery practice. In 1993, the same
authors surveyed surgery residents across Canada and found
that 19% of residents planned to pursue a standard general
surgery career and an additional 12% planned to be “gener-
alist” general surgeons (that is, they would do some subspe-
cialty procedures that would be of particular value in
nonurban settings) (12). The likelihood that a resident would
select the latter career option declined, however, with each
year spent in training. The authors speculate that a lack of
lackbothofexposure toappropriatementorsin thosesettings
and of prestige associated with such choices in the academic
community may contribute to the declining interest in gener-
alist careers. The residents identified professional collegial-
ity, hospital facility support, recreational opportunities, and
educational considerations for their children as important
incentives for a generalist career.
In light of these developments among our medical, pedi-
atric, and surgical colleagues, the creation of a general
60The?Canadian?Journal of PsychiatryVol 42, No 1
psychiatry division is both timely and consistent with trends
in training. The 4 challenges established at its inception in
• enhancing the current core (PGY2) year of training in
general hospital psychiatry mandated by the RCPSC
• creating “career-track” positions in general psychiatry
training akin to the subspecialization years in internal
medicine) for senior residents; creating postresidency fel-
lowship positions with the same clinical and academic
opportunities that exist for our psychiatric subspecialties
• providing community-based inpatientand outpatientexpe-
riences during residency training beyond the walls of the
• creating a niche within the university for the academic
generalist as a valued clinician, teacher, and researcher,
which also means working against an attitudinal and hier-
archical dichotomization of research and clinical care—as
if we could continue the idea that excellence in each can
exist independent of the other.
In reviewing our progress over the last 2 academic years,
3 important changes have been achieved. First, training
promulgated. These describe specific educational objectives
in termsofknowledge, skills,and attitudes.Thesepertainnot
only to the inpatient and outpatient experiences but also to
emergency psychiatry. Improved exposure to and training in
substance abuse—though still inadequate relative to the
invited to participate with staff in our Provincial Psychiatric
Outreach Program, working in inpatient and outpatient set-
tings in Northern Ontario; this has been so successful that
there is a waiting list of residents wishing to go on these trips
and increasing demand that such exposure be a mandatory
part of training. The application of these guidelines to the
teaching hospitals has had considerable effect, which may in
turn reflect their substance. Clinical teaching units have been
dropped as training sites, new mentors have been added, and
in vivo supervision of emergency work has become a norm.
This latter change has occurred in the larger context of
reorganization of emergency psychiatry training resources to
provide appropriate settings for achievement of academic
goals; this process has been contentious because of service
and resource implications for teaching hospitals. Copies of
the training guidelines are available from the corresponding
author on request.
Second, career-track positions in general psychiatry have
been filled at 4 teaching hospitals and have included senior
residents involving themselves in inpatient as well as outpa-
tient work—a change from earlier days when inpatient rota-
to graduate to outpatient, office-style practice. These resi-
dents have functioned as teaching fellows to junior residents
and medical students and have been allowed greater
autonomy with regard to supervision. A greater community
involvement has also taken place, with career-track residents
munity home nursing programs. Early feedback from these
to continue them postresidency. Several career-track resi-
dents have been recruited to fellowship positions in prepara-
tion for academic careers.
try division have played a prominent role in both education
and educational scholarship (innovations in course design
and evaluation) as previously described and have made more
modest contributions to research. They have been extremely
OSCE (observed structured clinical examination) format of
student evaluation and provision of both mandatory and
elective experiences for medical students. The use of the
OSCE format has itself generated data and findings in
first fellow in general psychiatry received peer-reviewed
salary support to allow pursuit of his research on psychiatric
education and completion of a graduate degree in that area.
Continuing education is an important component beyond the
clinical service of the Provincial Psychiatric Outreach Pro-
gram, and there has been an enthusiastic response from men-
tal health professionals in underserviced communities.
Faculty have also been involved in course development and
teaching of mental health and the law to law students and
in organization of conferences on emergency psychiatry for
community mental health professionals and perspectives on
psychotherapy integration. Completed research projects
since the inception of the division include a qualitative study
the use of televideo technology in providing psychiatric con-
pated in planning groups at provincial and community levels
to improvedeliveryofserviceswithina mentalhealthsystem
and to contribute to mental health reform in Ontario. Ulti-
in the academic and clinical directions taken by our trainees,
in 1997; they will be evaluated with regard to the impact of
the training guidelines.
In a university department with so many established aca-
demic subspecialties, one may rightly wonder where are the
such as suicide, however, traverse the boundaries of our
matrix and demand critical inquiry. In other regards, the foci
of general psychiatry will likely parallel those described
earlier for general pediatrics and general internal medicine,
that is, clinical epidemiology, ethics, and education.
February 1997Rediscovering General Psychiatry 61
Members of our division are already making significant aca-
demic contributions in these areas, but they need to be ex-
panded and to serve as a magnet for recruitment of residents,
fellows, and future faculty.
We hope our response to the 1994 British symposium “Is
it is at an early recovery stage after a long illness of neglect,
hoping to connect anew to both the university and the
• General psychiatry may suffer by training neglect.
• Subspecialization may dwarf generalization.
• Training must reflect community need.
• No systematic program evaluation.
Thanks to Paul Garfinkel for his comments on an earlier draft of
1.Gaughran F, Davies S. 1994 trainees’ forum: “is general psychiatry dead?”
Psychiatric Bulletin 1995;19:121–2.
Beigel A, Santiago JM. Redefining the general psychiatrist: values, reforms, and
issues for psychiatric residency education. Psychiatr Serv 1995;46:769–74.
Walter G. The psychiatrist in American cartoons. Acta Psychiatr Scand 1992;
McCormickW. Recruitment to under-serviced areas. Canadian Psychiatric Asso-
ciation Bulletin 1995;27:3–5.
College of Physicians and Surgeons of Canada 1995;28:172–4.
Cook DJ, Griffith LE, Sackett DL. Importance of and satisfaction with work and
medicine in Ontario. Can Med Assoc J 1995;153:755–64.
Petersdorf RG, Goitein L. The future of internal medicine. Ann Intern Med
Federated Council of Internal Medicine. General internal medicine and general
internists: recognizing a national need. Ann Intern Med 1992;117:778–9.
Haggerty RJ.The academic generalist: an endangeredspecies revived. Pediatrics
10. Helfer RE. The role of general pediatrics in an academic department. American
Journal of Diseases of Children 1992;146:545–7.
11.Chiasson PM, Roy PD. Training “generalist” general surgeons: a survey of
Canadian general surgery program directors. Annals of the Royal College of
Physicians and Surgeons of Canada 1995;28:269–71.
12.Chiasson PM, Roy PD, Smith-Chiasson AM. Factors affecting surgical career
choices: a survey of Canadian general surgery residents. Annals of the Royal
College of Physicians and Surgeons of Canada 1995;28:272–5.
Objectif : Décrire la raison d’être, les origines et les buts d’une division académique nouvelle de psychiatrie
générale dans un milieu universitaire.
Méthode : Tour d’horizon de la littérature, observations et description.
à atteindre certains de ses buts et à préciser des objectifs particuliers.
Conclusions : À une époque marquée par une sous-spécialisation universitaire croissante, le maintien de
compétences de base en psychiatrie et la reconnaissance du besoin public continu de psychiatres généralistes
doivent être enchâssés dans les programmes de formation universitaire.
62 The?Canadian?Journal of PsychiatryVol 42, No 1