Introduction

Liaison psychiatry is gaining a higher profile, both within psychiatry and in the general medical, surgical, obstetric and gynaecological specialities it serves. Most training schemes now include liaison psychiatry posts, and guidelines for training at higher levels have been agreed by the Royal College of Psychiatrists.

The number of consultant posts in liaison psychiatry has grown, although service provision remains patchy, particularly outside London and Edinburgh. In 1997, there were 86 consultants with some liaison sessions, and 38 FTE/HTE posts (1). In line with this expansion in service provision, there is a need for formal training opportunities where the issues unique to liaison psychiatry can be presented.

The Manchester Course in Advanced Liaison Psychiatry was set up by Professor Francis Creed and Dr. Else Guthrie in 1993. In the last five years, the number of delegates has increased three-fold, as has the distance some of them have travelled to attend. This year, colleagues from Italy, Sweden and Australia were welcomed, amidst a total of 27 participants.

This 5-day intensive course is aimed at Consultants and Specialist Registrars and assumes a Membership level of clinical knowledge making it unsuitable for SHOs.

What is taught?

The aims and objectives of the course are to focus on practical working issues facing a would-be consultant leading a half or full-time psychiatric liaison service. Specific clinical topics covered include:

• Finer legal and ethical points regarding the use of the Mental Health Act in deliberate self harm. How should we manage an actively suicidal terminally ill patient?
• Involvement of the A&E staff in active psychiatric liaison. What training is required to change attitudes?
• Somatisation. How should we manage a service for patients with medically unexplained symptoms who may be reluctant to engage psychologically?
• The psychological aspects of physical disease. What is the evidence-base for the use of adjuvant psychological treatment in irritable bowel syndrome?

Lectures, workshops, and case-presentations are given by leading academic and NHS consultants in Liaison Psychiatry, together with local clinicians including an A&E consultant and clinical psychologist, who represent the front line of day-to-day liaison psychiatry.

A wealth of practical information has been brought together and participants' feedback shows that they found the course "interesting and varied" and "an excellent preparation for a consultant post".

How is it taught?

The core teaching took a small group, problem-based learning approach. The group mix (and hence the often very lively group dynamics!) varied throughout the week and it was felt this was highly successful in engaging the trainees in lively active participation.

It received universally favourable feedback, although some felt that it was overused (with one person feeling "work-shopped to death!"). One participant felt (s)he had learned "how to be forward thinking and turn ideas into reality". Another commented: "This emphasis improves my skills and makes me more confident in analysing the local situation."

Underlying the success of the small-group format is the friendly and open atmosphere prevailing from day one. The lecturers are approachable, and generate an infectious positivism and enthusiasm for their subject, which even the drab surroundings could not quench.

Brainstorming in workshops also allowed a meeting of minds amongst trainees in a way that does not happen in the social intercourse in break times. Participants appreciated the "chance to meet like-minded doctors from outside my training scheme," as well as the "very open and pleasant atmosphere created by the trainers."

This year's European and Australasian input highlighted interesting differences between management styles and service provision issues overseas, as compared to the UK. We noted universal similarities regarding the need to improve psychological awareness in medical environments.

Who needs it?

Service provision requirements in the UK anticipate that one general psychiatrist per DGH will have responsibility for the liaison aspect of psychiatric provision within that hospital. Current provisions fall far short of this. Thus the need for explicit training in liaison psychiatry is important, in order to keep in line with other Western countries where 6 months of liaison training is mandatory.

The small group work focused on practical, hands-on issues which will form the bulk of the daily work of future hospital-based consultant psychiatrists.

• How do you launch a bid for employing a specialist liaison nurse in the A&E Department?
• How do you put forward a research proposal to evaluate a teaching intervention aimed at detecting mood disturbance in cancer patients?
• With the overwhelming psychological needs of medical patients that are not currently well-catered for in the NHS, how do you set up a viable liaison service, which is inevitably under-resourced, that will not be stretched beyond coping in the first few weeks?

This course is therefore highly relevant to those in general psychiatry positions with an interest in liaison, as well as old age psychiatrists who typically house a demanding hospital liaison component to their service. Specialist services such as cancer liaison or paediatric liaison pose further clinical opportunities.

What do participants take home with them?

The overall message of the course is that there are no easy answers to the host of issues in liaison psychiatry.

However, airing the issues, bringing together positive and enthusiastic speakers who have succeeded in making worthwhile niches for themselves in the turbulent world of the general hospital, and practising thinking through difficult scenarios, greatly enhances trainees' skills and confidence. More than anything, participants appreciated the focus on service management issues: "all the complicated stuff no one ever tells you."

Participants have the valuable experience of listening to senior colleagues being open and honest about the pitfalls and dilemmas awaiting them, whilst at the same time feeling part of a group of pioneers who can support each other in their endeavours to establish a much-needed service in a world of limited resources.

For a trainee to leave feeling that the course has "completely reinforced the idea that liaison is the right career for me" is a major success.

Feedback

Analysis of the feedback forms over the last 4 years indicates increasingly higher scores with respect to the four parameters shown in table 1, demonstrating a consistently high quality of course content.

Table 1: average scores for feedback parameters

1=very good, 2=good, 3=fair, 4=poor

Psychiatrists in planning meetings need help to answer those awkward questions our medical colleagues like to throw in, such as "What's the evidence that providing psychiatric input reduces recurrence of deliberate self-harm?" or "What's the evidence that psychiatry can reduce healthcare costs in patients with medically unexplained symptoms?"

Future additions to the course could include a take-home CD-ROM with the relevant evidence-base to hand. In the present climate of overwhelming demand on clinicians' time, the new consultant needs maximum help in order to put research findings into NHS practice.

No mention was made of the emergent field of psychoneuroimmunology which is contributing a rapidly expanding database of scientific evidence regarding the mind/body interface. With these advances, our understanding of the interplay between the psychological and the physical will be carried to new levels of sophistication.

Current training ignores this new information, and both general and liaison psychiatrists are at risk of being left trailing behind in a field in which they could be expected to take the lead. The Manchester curriculum cannot afford to stand still.

Conclusion

The Advanced Course in Liaison Psychiatry fills a huge gap in the training of future consultants.

Inevitably, it is not perfect, and the attendees have been prolific in their comments recommending additions, all of which would round out the training offered. Yes, including more on HIV, or obstetric and gynaecological topics, providing an opportunity to present difficult cases to a panel of experts, giving more information about on-going service evaluation - these are all topics of interest that could be included if time permitted.

As it stands, there is a good mix of topics with an excellent panel of speakers, and an active teaching style that is empowering to trainees. This course is now a "must-do" for any trainee with an interest in developing skills in liaison work, and should not be thought of as suitable for the specialist trainees alone.

The course goes a long way to meeting the need to impress our medical and surgical colleagues with well-equipped, practical and skilful liaison psychiatrists, which is what is required to generate sufficient enthusiasm to fund posts, and start meeting the Royal College's recommendation of 0.4 FTE liaison consultants per 100,000 population.

References

1. Guthrie E. Development of liaison psychiatry: real expansion or a bubble that is about to burst? Psychiatric Bulletin 1998. 22. 291-293

Written August 2000 by Nicki Crowley and Maya Spencer