Commentary and Perspective zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCB From time to time, the Journal receives manuscripts that can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and, if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting com- mentary with the understanding that all submissions are subject to editing. Medical Psychiatry Units and the Roles of the Inpatient Psychiatric Service in the General Hospital Paul Summergrad, M.D. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Abstract: The zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA medical-psychiutric unit concept has been the most important influence in the development of general hospi- tal inpatient psychiatry in the last decade. This concept and style zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA of unit organization is reviewed in the context of the history of general hospital inpatient psychiatry. It is suggested that elements of the medical-psychiatry unit model will become more important in the organization of general hospital psychi- atric units. Modifications of the medical psychiatry unit con- cept are suggested to take into account the heterogeneity of many general hospital inpatient services. Implications of these factors are discussed in the context of unit design, models of stuff organization, and the formation of networks of care. Introduction The development of medical-psychiatric units has represented the most important conceptual shift in general hospital inpatient psychiatric care during the past decade. This development, coming as it did within the context of the remedicalization of American psychiatry, has been widely heralded as an ideal model of inpatient psychiatric care. How- ever, the development of such units, as important as they are, has not been matched by changes in other treatment models previously dominant in general hospital inpatient psychiatry [l-12]. There have always been theoretical tensions over the proper role of the psychiatrist in the gen- Inpatient Psychiatric Service, Massachusetts General Hospi- tal, Harvard Medical School, Boston, Massachusetts. Address reprint requests to: Paul Summergrad, M.D., De- partment of Psychiatry, Bulfinch 440, Massachusetts General Hospital, Fruit Street, Boston, MA 02114. era1 hospital. For many general hospital psychia- trists the physician’s role, with responsibility for medical care in a more narrowly defined sense, has been paramount. For others, psychiatrists in the general hospital have been seen to hold a particu- lar responsibility to humanize all patient care and encourage attention to psychosocial factors in ill- ness among nonpsychiatrist colleagues. Both viewpoints were expressed by the founders of gen- eral hospital psychiatry and continue to find artic- ulate representation among their recent counter- parts [X3-16]. General hospital inpatient psychiatry has also been subject to many of these same tensions within the field. Forces embodying contradictory views of the nature of psychiatric illness and the role of the general hospital in its treatment have in the past helped to propel the growth of general hospital inpatient psychiatry in the following ar- eas: greater acceptance of psychodynamic psychi- atry, psychotherapy and later psychopharmaco- logic methods of treatment, increased availability of insurance for psychiatric hospitalization, the community psychiatry movement which empha- sized proximity of patients to sites of treatment, and the desire by some to have the general hospi- tal replace the state hospital as the primary locus of care [ 17-221. In order to place the development of medical- psychiatric units more fully into context and to look at related models of general hospital inpatient psychiatric care, it may be useful to review briefly, elements in the history of general hospital psychi- 20 ISSN 0163-8343/94/$7.00 General Hospital Psy&i&y 16, 20-31, 1994 8 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010