Acute general psychiatry: too hot in the kitchen?

Adult general psychiatry is the kitchen in the mental health residence. The elegant drawing room with its grand piano and wonderful acoustics is for psychotherapy, the long hallway with its many exits is for liaison psychiatry, the well-stocked library and crèche is for child and adolescent psychiatry, the quiet and homely sitting room with its many chairs is for old age psychiatry and at the rear is the spanking new extension for forensic psychiatry — next to the yard for substance misuse. But the heat emanates from the kitchen, where adult psychiatry has always had its home. Dr Colgan (pp. 3-4, this issue) describes how working in this kitchen now seems to be a chore, or “something that all psychiatrists do before specialising in something else”, whereas in the past, when it was Harry Truman's School of Cordon Bleu Cookery where everyone wanted to be, it was a training ground for the budding chefs who would stay in kitchens throughout their working lives. This was the hub of the house, where it was always active and busy, and its inhabitants were invariably envied and sometimes revered.

No discipline, whether it is for culinary cognoscenti or for psychiatric professionals, likes losing its specialist status. But just as cooking has become a profession for everyman, with young pretenders with limited talent dominating prime-time television, so has acute psychiatry become, in the space of only a few years, the pariah of the profession, where the many risks of assault by patients, of inquiries by officialdom and of burn-out through overwork are perceived as far outweighing the benefits. Small wonder, therefore, that many are forced into early retirement or a move to the less stressful private sector, at a time when the national shortage of psychiatrists is an acute problem (Kendell & Pearce, 1997).

“What is to be done?”, asks Dr Colgan. He suggests an obvious solution. Every other discipline has become a speciality and prospered as a consequence, so acute psychiatry should do the same. Cooks should have more qualifications and a longer period of training. They should have regular meetings with others in the feeding business and a long-term career structure. There should be a hierarchy of chefs and textbooks on cooking rather than best-selling fondue fluffs. If necessary we should march on television centres and boycott those who trivialise our trade.

Is this wise? One of the attractions of the kitchen, despite its cramped and hot working conditions, is that it copes with almost everything. Another famous Trumanism was “the buck stops here”, and indeed, everyone in acute psychiatry is aware of patients who are refused by other disciplines and are referred back to the service in what Colgan describes as the ‘default option’. But if acute psychiatry “sets out parameters of engagement”, who will look after those who are rejected? Where will the buck stop then? Some would argue the opposite; that we should make acute psychiatry the equivalent of general practice within medicine, and advertise its central role so it succeeds in recruiting the extra numbers of senior psychiatrists needed to restore order and remove the siege mentality prevalent in many inner-city services? One could then see acute psychiatry, like general practice, moving towards greater control of budgets and exerting influence far beyond its immediate environs. Good kitchens are still admired and the chef who can rustle up a marvellous meal from the most basic ingredients is often respected more than the specialist in the rarefied Ritz, so the best advice may be to stick it out — and turn on the fan.