European guidelines for training in consultation–liaison psychiatry and psychosomatics: Report of the EACLPP Workgroup on Training in Consultation–Liaison Psychiatry and Psychosomatics

Article Outline

• Abstract
• Introduction
• Methods of the consensus procedure
• Results
  • Results of the survey on training across EU
• Recommended training for residents in C–L psychiatry and psychosomatics
  • Goals and objectives of training
  • Organization of recommended training
  • Content of training in C–L psychiatry and psychosomatics
    • Knowledge
    • Skills
      • Communication skills
      • Diagnostic and formulation skills
      • Specific areas of clinical interventions
      • General aspects of working in C–L psychiatry and psychosomatics
    • Attitudes
• Recommendations for advanced training in C–L psychiatry and psychosomatics (fellowship)
  • Goals and objectives of advanced training
  • Organization of recommended training
  • Content of advanced training in C–L psychiatry and psychosomatics
    • Communication skills
    • Diagnostic and formulation skills
    • Specific areas of clinical interventions
    • General aspects of working in C–L psychiatry and psychosomatics
• Form of training
  • Tutorial and supervision
  • Case conferences
  • Seminars
  • Journal clubs
  • Courses and conferences
  • Assessment of competency and efficacy
• Conclusions
• Acknowledgments
• Appendix A. Questions on training in C–L psychiatry and psychosomatics
• References
• Copyright

Abstract 

Objective

The European Association of Consultation–Liaison Psychiatry and Psychosomatics (EACLPP) has organized a workgroup to establish consensus on the contents and organization of training in consultation–liaison (C–L) for psychiatric and psychosomatic residents.

Methods

Initially, a survey among experts has been conducted to assess the status quo of training in C–L in different European countries. In several consensus meetings, the workgroup discussed aims, core contents, and organizational issues of standards of training in C–L. Twenty C–L specialists in 14 European countries participated in a Delphi procedure answering a detailed consensus checklist, which included different topics under discussion.

Results

Consensus on the following issues has been obtained: (1) all residents in psychiatry or psychosomatics should be exposed to C–L work as part of their clinical experience; (2) a minimum of 6 months of full-time (or equivalent part-time) rotation to a C–L department should take place on the second part of residency; (3) advanced training should last for at least 12 months; (4) supervision of trainees should be clearly defined and organized; and (5) trainees should acquire knowledge and skills on the following: (a) assessment and management of psychiatric and psychosomatic disorders or situations (e.g., suicide/self-harm, somatization, chronic pain and psychiatric disorders, and abnormal illness behavior in somatically ill patients); (b) crisis intervention and psychotherapy methods appropriate for medically ill patients; (c) psychopharmacology in physically ill patients; (d) communication with severely ill patients and dying patients, as well as with medical staff; (e) promotion of coordination of care for complex patients across several disciplines; and (f) organization of C–L service in relation to general hospital and/or primary care.

In addition, the workgroup elaborated recommendations on the form of training and on assessment of competency.

Conclusion

This document is a first step towards establishing recognized training in C–L psychiatry and psychosomatics across the European Union.

Keywords: Consultation–liaison psychiatry, Education, Guidelines, Psychosomatics, Residency, Training

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Introduction 

In the last two decades, the number of psychiatric consultation–liaison (C–L) services increased in most European countries [1], [2]. Multicenter trials on care delivery and quality management in C–L were conducted by The European Consultation–Liaison Workgroup [3]. Besides C–L services run by departments of psychiatry, stand-alone C–L services of departments of psychosomatic medicine and psychotherapy were developed in Austria, Germany, and Switzerland [4], [5].

In spite of quantitative growth and the growing expertise of C–L psychiatry and psychosomatics, there are large differences in the consultation–liaison experience of residents at different sites and from different residency programs. There are serious shortcomings and unacceptable variations of the standard of training in this specialty of psychiatry across European Union (EU) countries [6], [7], [8], [9]. This contrasts markedly with several other parts of the world, notably Australia and New Zealand [10], Canada [11], and the USA [12], [13], where guidelines for residency training and advanced training have been established. In the USA, training in C–L psychiatry was supported by the National Institute of Mental Health in order to develop psychiatric and psychosocial care in general hospitals. Psychosomatic medicine has recently been recognized as an official subspecialty of psychiatry, with its own board examination and certification.

The European Association of Consultation–Liaison Psychiatry and Psychosomatics (EACLPP) was formed in 1997 to improve the management of patients with psychiatric disorders and psychological problems in medical settings by promoting the advancement of scientific knowledge and clinical practice in the field of C–L psychiatry and psychosomatics [14]. It aims to: (a) improve information exchange among members of the association and to educate the general public regarding C–L psychiatry and psychosomatics; (b) develop and promote standards for the training and practice of C–L psychiatry and professional conduct within the field; and (c) provide a forum for the presentation, dissemination, and discussion of scientific problems in C–L psychiatry and psychosomatics through the organization of meetings, conferences, workshops, and publications.

These guidelines for approved training in C–L psychiatry and psychosomatics have been prepared in relation to Item (b) above. It reflects a consensus drawn from representatives of EU countries prior to the enlargement of the EU in 2004.

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Methods of the consensus procedure 

An EU-wide workgroup (members are listed above) that derived these training guidelines was established in 2001. The following actions were undertaken to achieve a consensus on standards of training and to establish national and European guidelines:

The results of the expert meetings were documented in detailed protocols.

A formal Delphi procedure [15] was then conducted. Delphi begins with an open-ended questionnaire or with preselected items (drawn from reviews of the literature or interviews with selected content experts) that are given to a panel of experts to solicit specific information about a subject or content area. In subsequent rounds of the procedure, participants rate the importance of individual items and also make changes to the phrasing or substance of the items. Through a series of rounds, the process is designed to yield a consensus. In our case, a panel of 20 experts in the area of C–L psychiatric and psychosomatics from 14 European countries took part in this procedure. They agreed or disagreed on a detailed preliminary consensus protocol, which was elaborated based on the protocols of the Lisbon and Zaragoza expert meetings. The protocol included 37 items concerning the objectives, contents, and organization of: (a) training in C–L for psychiatric residents, and (b) advanced training in C–L (fellowship training). Panel members were also asked to make comments and to suggest rephrasings of the items.³ The answers were collected by the first author and documented in a consensus report. There was high overall agreement already in the first round of the procedure (between 75% and 100%). During the two subsequent rounds, the results of previous rounds were fed back to panel members, and they were asked to re-rate the newly formulated items based on the results of the previous rounds. Finally, a ≥90% agreement was reached in all items.

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Results 

Results of the survey on training across EU 

On general residency in some countries, C–L psychiatry or psychosomatics⁴ forms part of the rotational training program. Rotation to a C–L service is mandatory in Spain (full time for 4 months) and Portugal (full time for 3 months on the third or fourth year of psychiatry training). It is recommended in Norway (full time for 6 months), the United Kingdom (full time for 6 months), and Germany (psychosomatics: half time for 3–6 months; psychiatry: no time frame). Mandatory training in C–L will be included in the residency in The Netherlands (in 2006) and Austria (in 2007). A mandatory 1-year rotation to internal medicine is required for psychosomatic specialty in Austria, Norway, and Germany. A 1-year rotation to neurology is required for psychiatric specialty in Austria and Germany.

In some countries, residents in the general program need a specified number of supervised consultations in C–L psychiatry or psychosomatics. In Germany, this equals 20 consultations [16]; in Italy, it equals 25 [17]. The number of seminars/case conferences required for approved training varies between 10 and 128 h in different countries. Some centers with extensive experience with C–L work offer short-term full-time C–L courses [18], which are attended by C–L psychiatrists and psychosomaticists from the respective countries but also from other European countries.

There are formal and published national guidelines for training in C–L psychiatry in the United Kingdom [19] and Spain [20], and in C–L psychosomatics in Germany [21]. In The Netherlands, guidelines were developed by The Netherlands Consortium of Consultation Psychiatry, which were later acknowledged by the Section of General Hospital Psychiatry of the Dutch Psychiatric Association [22].

Official recognition of advanced training in C–L psychiatry or psychosomatics exists in the following countries. In Finland, a 2-year approved training leads to the recognition of “special competence” in general hospital psychiatry [23]; in the United Kingdom, a special endorsement in C–L psychiatry as part of specialist training requires at least 1 of 3 years of full-time training in a C–L unit.

The following problems were observed in the current training on C–L psychiatry and psychosomatics:

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Recommended training for residents in C–L psychiatry and psychosomatics 

Goals and objectives of training 

The training of residents during their rotation to a C–L clinical experience should take place on the second half of the residency and is based on the attitudes, knowledge, and skills acquired during their residency program in general psychiatry or psychosomatics. Rotation to a C–L unit should add specific attitudes, knowledge, and skills to the residency program. Graduates of residency training in C–L should be able to:

Organization of recommended training 

All trainees should be exposed to C–L work as part of their clinical experience in general psychiatry and psychosomatics. This, in itself, is inadequate, however, because (a) residents often have a heavy workload in general psychiatry and C–L component may be minimal; and (b) supervision of the C–L component is often inadequate because a consultant trainer has had no specific training/experience in C–L psychiatry/psychosomatics and/or because the supervision only covers the general psychiatry part of the resident's clinical work. For these reasons, we recommend training in C–L psychiatry and psychosomatics if it fulfils the following criteria:

Content of training in C–L psychiatry and psychosomatics 

The trainee in C–L psychiatry and psychosomatics should acquire knowledge, skills, and attitudes.

Communication skills 

Diagnostic and formulation skills 

Specific areas of clinical interventions 

General aspects of working in C–L psychiatry and psychosomatics 

The trainee in C–L psychiatry or psychosomatics is expected to develop appropriate attitudes as a psychiatrist or psychosomaticist working as a member of a multidisciplinary team, whose other members do not have psychiatric training or background. This is different from the multidisciplinary team in mental health services. For example, in the general hospital or primary care setting, the psychiatrist or psychosomaticist may have to: (a) be an advocate for the patient; (b) preserve confidentiality even when under pressure to disclose confidential details; (c) insist on psychological aspects of care when these are in danger of being disregarded; (d) ensure that mental health legislation is used appropriately; (e) help teams when differences of opinion regarding the management of a patient occur and when the team is faced with an ethical dilemma.

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Recommendations for advanced training in C–L psychiatry and psychosomatics (fellowship) 

Goals and objectives of advanced training 

In addition to the goals and objectives of C–L training for residents, graduates of advanced training should become specialists in C–L psychiatry and psychosomatics who are able to deal with complex and difficult problems in the interface between psychiatry and medicine. In particular, they should be able to:

Organization of recommended training 

Content of advanced training in C–L psychiatry and psychosomatics 

A trainee in fellowship programs of C–L psychiatry or psychosomatics should intensify knowledge, skills, and attitudes that are described in the resident's training in C–L (see Content of Training in C–L Psychiatry and Psychosomatics). Additionally, advanced training should include knowledge and skills in several areas.

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Form of training 

Training in C–L psychiatry and psychosomatics takes place in several forms.

Tutorial and supervision 

All trainees should be supervised by a named attending physician with experience in C–L psychiatry/psychosomatics (tutor). During the early part of the rotation, trainees should accompany the attending C–L psychiatrist while performing clinical consultations. Trainees should be able to observe all elements of a consultation process and discuss it in supervisory sessions. Trainees should be given the opportunity to experience permanent C–L staff informal meetings and communication, and direct and indirect supervision of other doctors and other staff members involved in the care of patients seen by C–L psychiatrists in general hospitals. The supervisor should have the opportunity to observe the trainees perform an entire consultation, providing the trainees with appropriate feedback.

Case conferences 

Attendance at case conferences should be weekly. Case conferences should usually be interdisciplinary (primary care physician, general hospital ward staff, social worker, etc.), conducted by a full-time C–L psychiatrist or psychosomaticist, and open to physicians from other wards, nurses, medical students, and psychiatric rehabilitation students (compare to the Modena model [17]). The trainee should present cases, and medical staff members who are responsible for a patient should be invited to contribute to a case presentation. The trainee should present at least one written comprehensive case history. Actively participating in case conferences reifies and builds professional identity.

Seminars 

Trainees should attend seminars on theoretical topics and skills training.

Journal clubs 

Trainees should be given access to journals dedicated to C–L work, as well as to general medical and general psychiatric journals. Textbooks in C–L psychiatry and psychosomatic medicine are now readily available [24], [25], [26], [27].

Courses and conferences 

Short-term full-time C–L courses at “centers of excellence” should be promoted. Attendance at annual national C–L meetings or EACLPP conferences should be encouraged for trainees to enhance their skills (follow-up/refreshment courses) and also meet C–L trainees from other centers.

Assessment of competency and efficacy 

Assessment of competency and efficacy includes the following:

Concerning examinations, competency measures should be developed and experiences from other countries should be analyzed [28], [29], [30], [31]. Residents should also evaluate supervisors.

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Conclusions 

The current state of training in C–L psychiatry and psychosomatics shows serious shortcomings and unacceptable variations across EU countries. This document is a first step towards establishing recognized training in C–L psychiatry and psychosomatics across the EU. At present, the EACLPP is seeking approval for the following:

This will enable trainees to develop specialist skills required for this work, which are likely to grow as the importance of psychiatric disorders in general medical settings is increasingly recognized.

We have to address a limitation of these guidelines. The consensus report was derived almost exclusively from EACLPP members and acknowledged experts in the field of C–L psychiatry and psychosomatics. A consensus report including a broader range of psychiatry program directors might have led to somewhat different results (such as, maybe, a shorter rotation to C–L training during residency). However, we think that a consensus report derived from leading European C–L experts is an important first step to developing European quality standards in training residents and fellows in C–L psychiatry and psychosomatics.

Following these guidelines, C–L training has to be developed and implemented on a national level. C–L units that provide such training must meet quality standards for the organization of training. A psychiatric or psychosomatic institution or service that offers training in C–L should be certified by national boards/societies of psychiatry or psychosomatics. Psychiatrists or psychosomaticists responsible for the training of residents and fellows should have extensive expertise in C–L work. They should be also certified by national boards and societies of psychiatry or psychosomatics. On a European level, C–L units with a high level of experience in clinical practice, in research and training, and in meeting specific requirements (“centers of excellence”) should provide intensive courses in C–L psychiatry and psychosomatics. These centers and intensive courses in C–L should be approved by the EACLPP. The EACLPP workgroup on training is currently establishing guidelines for the accreditation of such courses.

Finally, we are convinced that training in C–L plays an important role in forming the professional identity of psychiatric residents, as Kornfeld [32] pointed out in his overview on the impact of C–L psychiatry on medical practice: “I believe that there is nothing more powerful than a good consultation–liaison experience to reinforce young psychiatrists' perception of themselves as members of the medical profession.”

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Acknowledgments 

We thank the following colleges who contributed to the development of the guidelines: Albert Diefenbacher (Berlin, Germany), Per Fink (Aarhus, Denmark), Else Guthrie (Manchester, United Kingdom), Thomas Herzog (Göppingen, Germany), Pirrko Hiltunen (Helsinki, Finland), Frits Huyse (Groningen, The Netherlands), Navnet Kapur (Manchester, United Kingdom), Peter Lange (Rosenheim, Germany), Albert Leentjens (Maastricht, The Netherlands), Geoffrey Lloyd (London, United Kingdom), Ulrik Malt (Oslo, Norway), Anders Lundin (Stockholm, Sweden), Ben Ruesink (Amsterdam, The Netherlands), Graeme Smith and Marina Vamos (Melbourne, Australia), Pascal van Vaeck (Paris, France), Edwina Williams (London, United Kingdom), Tom Wise (Baltimore, MD, USA).

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Appendix A. Questions on training in C–L psychiatry and psychosomatics 

1. Do guidelines for training in C–L psychiatry and/or psychosomatics exist in your country? Are they published? (If available, please add a reference or a copy.)

2. Is training in C–L psychiatry and psychosomatics part of the training program for psychiatric residents? If yes, is it

( ) Mandatory

( ) Recommended

( ) Optional

3. Is training organized nationally or locally?

4. How is the organization and what is the time frame of the training?

5. Does theoretical training include the following:

	Yes/no	If yes, how many hours?	Comments (e.g., kind of “other” courses)
Theoretical training
1. Delirium and dementia
2. Somatization
3. Treatment of suicide attempts
4. Interaction of psychotropic drugs
5. Other courses
6. Total theoretical courses

6. Does skills and practical training include the following:

	Yes/no	If yes, how many hours?	Comments (e.g., kind of “other” courses)
Training of special skills
1. Focused psychotherapy
2. Relaxation techniques
3. Group psychotherapy
4. Systemic approaches
5. Team counseling
6. Other skills training
7. Total skills training
Clinical experience
1. Supervised clinical practice
2. Supervision/case conferences
3. Quality management meetings
4. Rotation to C–L units
5. Rotation to medical/surgical units
6. Other
7. Total clinical experience
Skills and practical training total

7. Please add some more information on the main topics of the training, if necessary.

8. Is there a formal procedure for finishing the training (certificate)?

9. Are follow-up sessions or meetings for further education organized?

10. Do requirements concerning teachers of such training exist?

11. What are the costs of such training? Who pays the fees?

12. Which next steps would you consider necessary, or do you plan for the future?

13. Add personal comments.

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• 2 The questionnaire was sent out in 2002 before the enlargement of the EU to Eastern European countries.
• 3 The consensus protocol may be obtained from the EACLPP Web site (www.eaclpp.org).
• 4 In Germany, psychosomatic medicine is a specialty on its own, apart from general psychiatry and child psychiatry. In Germany and other German-speaking countries, both psychiatric and psychosomatic C–L services exist in tertiary-care general hospitals. Services differ in relation to the patients referred and the methods applied: patients with delirium and dementia are predominantly referred to psychiatric C–L services, and patients with anxiety or adjustment disorders are referred to psychosomatic C–L services. While general psychiatry runs consultation services and applies pharmacological treatment in most cases, psychosomatic medicine mainly runs liaison services and uses psychotherapeutic methods [4].