Ignasi Agell explains this branch of psychiatry in the United Kingdom

At medical school, your experience of psychiatry is mainly limited to an attachment to a psychiatric service, which is likely to be in general adult psychiatry. Spending occasional time in clinics and on ward rounds trying to elicit symptoms may have given you the impression that you will never use these skills after your exams, unless you want to be a psychiatrist. Nothing could be further from the truth because psychiatric problems are present in all branches of medicine.

• Psycho-oncology--The interface with oncology is a growing field, especially in the aspect of communication skills. It also concerns the psychological aspects of end of life care and palliative care
• Psychosexual--Psychosexual problems are prevalent in certain conditions like diabetes where a high percentage of male patients report sexual dysfunction
• Neuropsychiatry--A huge field because any brain injury has consequences. It is currently developing as a distinct subspecialty
• Paediatric and old age liaison psychiatry--This is liaison psychiatry with the added consequences of patients of extreme ages, which has implications for both presentation and management
• Chronic fatigue syndrome--A diagnosis based in a presenting syndrome rather than a cause. The number of liaison psychiatrists working in this area is growing, because chronic fatigue syndrome is increasingly recognised
• Deliberate self harm--Many liaison services start in general hospitals with the assessment and management of suicidal patients

What is liaison psychiatry?

Liaison psychiatry is a subspecialty within psychiatry, which is concerned with the overlap between psychiatry and the rest of medicine and surgery. Its scope ranges from psychological reactions to physical illness, deliberate self harm, and somatoform disorders, among others.

Mind and body divide

We owe to Descartes, the French philosopher, the unfortunate divide in our thinking between mind and body. Liaison psychiatry brings them together during assessment and treatment, and also in education through teaching and supervision of other health professionals. A good liaison service should help you to develop further the skills you thought you would never use again outside psychiatry. One of those skills is understanding your patient now in relation to his or her past and the current social circumstances without forgetting the biological perspective; liaison psychiatry is about bringing these together.

Psychiatric skills

In many cases you will be able to help your patients using minimal psychiatric skills, but some patients will require more specialised skills -- both psychological and pharmacological. These skills are different from the skills used in general psychiatry because of the different presentations and the context of a medical setting.

Teamwork

If you want to be a liaison psychiatrist then you need to enjoy working in a team. This is important because liaison services are multidisciplinary in nature, but also because you will spend a lot of your working time developing links with other services providing an educational role and providing support and supervision to other health professionals.

Subspecialties

Liaison psychiatry services are not sufficiently developed to be divided into subspecialties but many liaison psychiatrists develop specific areas of interest, each with its own particular differences. Some are listed in the box, but they can be extended to any medical or surgical speciality.

The training

Training starts as a general adult psychiatrist with a special interest in liaison psychiatry. The only specific requirement is that you should complete one year out of the three in higher specialist training in a recognised liaison post.

Basic specialist training

As a senior house officer you rotate every six months around different subspecialties. There are minimum requirements to sit Member of the Royal College of Psychiatrist exams, parts one and two; you should look at the Royal College of Psychiatrists' website as requirements can change. You spend at least three years as a senior house officer before being eligible to go into higher training. Note that every six months in a specialty that is not psychiatry but is still relevant count towards your training--for example, emergency medicine and general medicine. Knowledge of other specialties is important, especially if you already know you want to be a liaison psychiatrist.

Higher specialist training

This takes three years for a single accreditation, and four or five if you are training for double accreditation (like general adult and old age). For liaison psychiatry you need to spend at least one year of your higher specialist training in a recognised liaison post. The other requirement is a year in a core general psychiatric post. As services in liaison psychiatry vary enormously around the country, the training can also vary, ranging from only self harm to liaison psychiatry with inpatients. Psychiatry is generally a good specialty to train flexibly, and liaison psychiatry is no exception.

Career prospects

A career in psychiatry currently lacks the extreme competition that exists in other specialties. This allows you to enjoy your training, mainly at specialist registrar level, as you are given one day a week for research and one day a week for you to develop your special interest sessions. The downside in liaison psychiatry as a recent subspecialty is the low number of consultant posts, although they are increasing.

My experience

I started training in surgery but became disillusioned with it. I entered psychiatry as I remember enjoying it as a medical student, and then I discovered liaison psychiatry. I completed my basic training luckily having rotated through a great number of subspecialties, each of them providing different skills that I can use in liaison psychiatry. My previous surgical training gives me an insider's knowledge of what is expected of me as a liaison psychiatrist and this, in my opinion, is invaluable. Training in liaison psychiatry has also given me the opportunity to develop managerial and teaching skills.

Pros

• Intellectually rewarding as challenging cases are the norm
• Opportunities for developing services because it is a new discipline
• Opportunities for teaching and research
• Teamwork

Cons

• Risk of becoming professionally isolated
• Difficulties with funding services
• Difficult to work if other medical colleagues are not receptive of liaison psychiatry

A day in my life

After sorting out my correspondence, I attend to some of the referrals the service has received for the day. I particularly enjoy this part of the job, as I enjoy working on a hospital ward. Assessing a new patient can be time consuming, and it is important not to jump to conclusions until the assessment is completed which can take more than one visit. Action plans can include more than one professional, so clear channels of communication are important. About lunchtime, I work with the self harm team--senior house officers and non-medical health professionals. They have assessed patients in the emergency department and on the medical ward, and I discuss these cases further with them. I have a clinic in the afternoon with one new patient each week. It takes an hour to complete a psychiatric assessment and negotiate the management. Follow up sessions are half an hour. Cases vary greatly--for example, non-epileptic seizures, hypochondriasis, and depression after mastectomy.