Specialization

In his Viewpoints article in the March 6 issue, "What or Who is a Psychopharmacologist?," Jerry M. Wiener, M.D., rightly questions the proliferation of the designation "psychopharmacologist."

He concedes the fact that members of any specialty or profession may develop skills and expertise that qualify them to be considered subspecialists. He sees this development in psychiatry, however, as entailing nefarious motives and/or dire implications, and he is wrong on both counts.

As the base of knowledge and skills in psychiatry expands, it is both natural and desirable that practitioners should become more adept in some areas than in others. Does the fact that some internists subspecialize in endocrinology imply that they believe gastroenterology is "irrelevant" or "less important"? Is it reasonable to expect all psychiatrists to be equally skilled at conducting all of the potentially effective psychotherapeutic approaches for all psychiatric illnesses, in addition to possessing a high level of knowledge about and skill at using all of the potentially effective pharmacotherapies?

It appears that Dr. Wiener is more alarmed at the practice of psychiatrists' sharing patients with nonphysician psychotherapists than he is at, say, the practice of orthopedic surgeons' sharing patients with physical therapists, because of the fundamental implications he ascribes to the former phenomenon. Specifically, he sees separating the provision of psychotherapy from that of pharmacotherapy as "splitting off mind from brain." Although mind/brain dualistic fallacies are unfortunately rampant in psychiatry (as they are in all of medicine and society), Dr. Wiener's conceptualization serves only to ratify those misconceptions. His apparent belief that pharmacotherapies treat the brain while psychotherapies do not is theoretically incoherent and demonstrably false. It is thus equally false to conclude that the development of specialists in pharmacotherapy has implications for psychiatry's position on the mind/brain problem.

Nonetheless, I agree with Dr. Wiener that the way psychiatry defines itself, the way the rest of medicine and the public define our field, and the influence that managed care exerts over these questions are topics of great import to which we all should pay more attention.

G. Scott Waterman, M.D.
Burlington, Vt.