Abstract
The first day of the International Year of Older Persons was 1 January 1999, and on that day the Section of Psychiatry of Old Age (SPOA) became the Faculty of Psychiatry of Old Age (FPOA), the second Faculty of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Many in the College may wonder about the significance of the transformation, especially since at least three other Sections are planning the equivalent change. In essence, how does a Faculty differ from a Section?
A Section of the College is an interest group bringing together Fellows and affiliates who share an interest in a field of psychiatry. No specific expertise is required to belong to a Section, there are no entry criteria apart from payment of dues. In contrast, members of a Faculty must be recognised as having expertise in that specialty area, obtained through training and/or experience. This will be a prerequisite in determining who is eligible for foundation membership of the new Faculty.
According to the College by-laws, there are two criteria required for the formation of a Faculty. First, it must be demonstrated to General Council that the Faculty represents an internationally recognised body of knowledge in psychiatry. Second, there is a College accredited training scheme.
1. Recognised body of knowledge
The fact that a number of specific textbooks on old age psychiatry have been written (including one of Australian origin [1]) is testament that this is a distinct specialty, with its own body of knowledge. Several journals with an international circulation are devoted to psychiatry of old age, and space is given in a number of gerontology and aged care journals to psychiatric disorders.
The specialty is young. The first comprehensive specialist psychiatric services for elderly people were developed in the UK in the 1960s [2] and old age psychiatry became a specialty within the UK National Health service in 1989 [3]. By 1996,134 senior registrars in England and Wales were enrolled in old age psychiatry. The Royal College of Psychiatrists now has a Faculty of Old Age Psychiatry.
In Australia and New Zealand, catchment area psychiatric services for older people have developed rapidly since the 1980s, so that a majority of elderly persons in both countries now have access to them. The binational RANZCP gave recognition to this development of psychiatry of old age by approving terms of reference for SPOA. These had been considered at a meeting of psychiatrists and other health professionals in Sydney in December 1987 after many years of informal discussions. Since that time there have been regular clinical meetings of members and affiliates of the Section (now Faculty). There has been worldwide recognition of the breadth, quality and importance of research and publications from Australia and New Zealand in relation to mental disorders in old age [4].
In 1990, SPOA and the Geriatric Psychiatry Section of the World Psychiatric Association (WPA) co-hosted a seminar in Melbourne, Australia, on functional disorders in old age. This was a trail-blazer for the successful 1995 International Psychogeriatric Association (IPA) congress in Sydney, which was organised and co-hosted by SPOA. Another IPA seminar will be co-hosted by the Faculty at Lome, Australia, in 2001.
These associations with IPA, the pre-eminent organisation that represents the interests and aspirations of old age psychiatry around the world, go beyond conference organisation. Three out of 30 on the Board of Directors are from Australia, including the president (E. Chiu). We hope there will be a New Zealand representative as well. The Faculty also has members in senior positions in Alzheimer's Disease International and the Geriatric Psychiatry Section of the World Psychiatric Association.
In 1998 Reifler and Cohen [5] conducted a survey to determine how well psychiatry of old age was progressing in various parts of the world. IPA members in 64 countries responded to a questionnaire. The UK was found to be the country where development of the specialty as a profession was most advanced, though it ranked second to the Netherlands in development of psychiatric services for older people. Australia and New Zealand were ranked near the top in terms of the development of geriatric psychiatry as a profession, and in development of services for mentally ill older people. If the survey were to be repeated in 2000, the ranking would be even higher because of the advent of the FPOA and the new arrangements for training and accreditation.
Soon after the formation of SPOA, its executive (and particularly its first chair, E. Chiu) started planning for Faculty status. A major motivation for this was to obtain representation on the RANZCP General Council. It was hoped that such representation would draw attention to the special mental health needs of older people, and the need for specific old age services. Not all Fellows of the College are persuaded by arguments to provide resources and services to older people that are equal to or greater than those provided to younger adults. SPOA needed opportunities to counter ageist attitudes within the College and the wider community, and to advocate and develop services of the type observed to be effective in the UK. It was considered important to reinforce interest in problems encountered by older people, and to ensure that health professionals were well trained in how to deal with them. It was also important to expand our body of knowledge through research and evaluation.
2. Developing a College-accredited training scheme
Training in psychiatry of old age is distinct from general training (albeit containing all of the same basic elements). When creation of the Section was ratified by resolution of General Council of the RANZCP in April 1988, SPOA's terms of reference included the objective ‘to develop and participate in training programs in psychiatry of old age for trainee psychiatrists …’. The inaugural annual general meeting (AGM) was held in Adelaide in 1988 in association with the Australian Society of Psychiatric Research meeting. Education was one of the main priorities of the Section enunciated at that meeting, early concerns being the lack of mandatory training in psychiatry of old age for general trainees. In 1992 SPOA set up a working party on training issues with two main aims. The first of these was to examine the psychiatry of old age educational needs of trainees preparing for Section 1 of the Fellowship examination. The second was to ascertain the training requirements of advanced trainees intending to sub-specialise in psychiatry of old age.
The goals of the working party included the development of guidelines for training in psychiatry of old age that would be appropriate for all training programs in Australia and New Zealand, and to develop curricula both for Section 1 and for advanced training. To assist in this process, all psychiatry trainees and training program coordinators in Australia and New Zealand were surveyed during 1992, the results being published in this Journal [6]. It was found that while 94% of trainees believed that they required at least 3 months training in psychiatry of old age, this was being obtained by only 70%. Some 13% of trainees indicated that they wanted to specialise in psychiatry of old age, while a further 21% indicated an interest in the field.
International experiences of advanced training in psychiatry of old age were canvassed in meetings, in correspondence and by literature searches. In the UK, the Joint Committee in Higher Psychiatric Training of the Royal College of Psychiatrists issued a position statement in 1989 that provided details of the training experiences required for someone seeking to work full-time in old age psychiatry. This included 2 years in general psychiatry and 2 years in old age psychiatry that included experience of two different services and supervisors [7].
In the USA, the American Board of Psychiatry and Neurology established a committee on certification in added qualifications in geriatric psychiatry. This helped establish geriatric psychiatry as a subspecialty in 1993 and provided a means of identifying properly trained and experienced geriatric psychiatrists. This committee recommends minimum standards both for training centres and for training requirements. A 1-year fellowship in geriatric psychiatry must be undertaken no sooner than the fifth postgraduate year of training followed by an examination [8]. The American Academy of Geriatric Psychiatry, founded in 1978, recognises these added qualifications for membership purposes.
General psychiatric training in Canada is under the auspices of the Royal College of Physicians and Surgeons of Canada (RCPSC). In 1994, the Canadian Academy of Geriatric Psychiatry approved advanced training guidelines that outlines the goals and objectives of training, a training program structure, allocation of resources, a curriculum and evaluation procedure [9]. The training period has to be a minimum 18 months' duration. A joint proposal from representatives of child psychiatry, geriatric psychiatry and forensic psychiatry to the RCPSC in 1997 to create three new subspecialties has yet to prove fruitful [9]. In part, this is due to the RCPSC's reluctance, across all medical fields, to increase the number of subspecialties in Canada.
Several of the curricula in psychiatry of old age developed in the USA and Canada have been published [10,12]. Our own curriculum and recommendations for clinical experiences drew from each of these sources, with adaptations for local conditions, to form the ‘Guidelines for RANZCP Training in Psychiatry of Old Age’. They were completed in early 1995 after extensive consultation with senior SPOA members. They were designed to assist training program committees and supervisors to provide training experiences in psychiatry of old age both for Section 1 trainees intending to practise general psychiatry in an ageing society and for trainees seeking advanced training in psychiatry of old age. It was hoped that these guidelines would encourage training programs to expose all general trainees to psychiatry of old age as part of their training rotations.
At its 1996 AGM, SPOA decided to formally apply to General Council to become a Faculty of the College. An intrinsic part of that process was the need to demonstrate to the College Fellowships Board that the proposed Faculty was capable of organising a training scheme. During preliminary meetings with the Fellowships Board, SPOA was asked to redraft the curriculum so that it was consistent with the style of the Fellowship Curriculum that had been prepared by the Fellowships Board and released in September 1995. Redrafting was completed in 1997.
SPOA received much assistance from the College Executive, Fellowships Board and the Faculty for Child and Adolescent Psychiatry in developing our training by-laws. The training scheme of the Faculty of Child and Adolescent Psychiatry has been used as the template, with adaption of their organisational structure and assessment process to suit psychiatry of old age. One of the outcomes of this procedure was that the Fellowships Board recognised that there were other Sections developing their Faculty ambitions, and that there was a need for generic advanced training by-laws. These, together with SPOA's submission to become a Faculty, were approved by General Council at its meeting in October 1998. Thus, FPOA now has a Committee for Advanced Training in Psychiatry of Old Age, which is responsible for accreditation of FPOA training and which reports to the College Fellowships Board.
A major difficulty that we have to overcome with our training scheme is that we have a relatively small number of trainees spread over two countries. A large proportion have little contact with other advanced trainees. We have decided to utilise the internet as one way of countering this problem and have commenced internet tutorials through a chat program. These are led by senior Faculty members on prearranged topics. At the time of writing, four tutorials have been held. It is a novel experience for all participants, and while limited by technological (e.g. lines dropping out) and human failings (e.g. slow, inaccurate typing), there is sufficient promise to indicate that it may achieve its objective. Our reading list will also be posted on our web page later this year along with other training information. Trainees are also encouraged to obtain formal tuition through one of several distance learning courses that are available in psychiatry of old age, for example, through the University of New South Wales and the New South Wales Institute of Psychiatry.
Conclusion
The RANZCP now has two Faculties. When in due course Faculty status is approved for other psychiatric specialties (such as consultation-liaison, forensic, drug and alcohol, and psychotherapy), consideration will need to be given to the respective roles of branch and Faculty representatives on the College General Council. It is important for interest groups within the College to have opportunities to inform others of their views and needs, and for the different groupings to form a cohesive and cooperative whole.
At the same time, it is important for specialty groups to link with others who share their interests. For FPOA, linkages with geriatric medicine, gerontology, and with old-age psychiatry associations overseas are important. The Faculty is keen to work within the College but to retain an appropriate measure of autonomy and control over its own finances and activities. Through its entrepreneurial activities (particularly the 1995 IPA congress) it has accumulated funds which could be used to foster developments within the specialty. This has also allowed us to function without grants from the College. We seek support of other specialty groups for this approach.
Much hard work lies ahead. The training scheme is in its infancy and teething problems are anticipated. There are challenges for the Faculty as it lobbies for attention to the needs of older people. An auspicious grant of funds from the New South Wales government to the new Faculty's New South Wales branch to develop service delivery guidelines is a good start. We hope that partnerships with governments, nongovernment organisations and older persons themselves will lead to innovative developments in the new millenium.