Towards Implementing the Biopsychosocial Factor in National Health Care Systems: The Role of Postgraduate Training in Austria

who have graduated at a medical university and work either as resident physicians or fully licensed physicians. Tuition fees have to be paid for all parts of these courses. The Psy-Curricula are geared towards doctors of all medical fields to facilitate integration of psychosomatic medicine into several areas, e.g. primary care, psychiatry, internal medicine and gynaecology. However, there is no medical specialty or subspecialty in psychosomatic medicine in Austria. The Psy-Curricula consist of three consecutive levels: ‘psychosocial, psychosomatic and psychotherapeutic medicine’ ( table 1 ). Graduation at each level is documented by a diploma. Training for level 1 (Psy-1, Diploma for Psychosocial Medicine) takes approximately 1 year (180 h). At this level, training focuses on medical history taking based on the biopsychosocial model and on improving communication strategies. Furthermore, it informs physicians about treatment options in the psychosocial field [4] . After an additional 2 years (480 h), trainees can complete level 2 (Psy-2, Diploma for Psychosomatic Medicine). Training at this level qualifies doctors for psychosomatic care including the diagnosis of complex biopsychosocial interaction and integrative approaches to treatment. At level 3 (Psy-3, Diploma for Psychotherapeutic Medicine), after a further 3 years of training (1,870 h), full psychotherapeutic competence is achieved. Supervision, Balint group training and participation in self-awareness groups are integrative parts of these Psy-Curricula. A continuously growing number of medical doctors has already completed one or more levels of this programme and has been certified by the Austrian Medical Association. Among all 39,123 medical doctors in Austria in 2009, 2,101 medical doctors have obtained the Psy-1 diploma, 1,669 have reached the Psy-2 level and 1,232 have been certified with a Psy-3 diploma. About 10% of all Austrian general practitioners who work in private practice have successfully attended at least one of these courses [4] . About half of all physicians who have graduated with a Psy-3 diploma are psychiatrists. Thus, general practice and psychiatry contribute to this programme with the largest groups of participants. In 1 of 6 training centres for the Psy-Curricula two evaluation studies focused on the effects of this programme [5, 6] . Results of one of these studies, based on 30 study participants, suggested a significant increase in patient-centred communication of medical doctors before they had started Psy-1 and after completion of Psy2 [5] . Another study investigated the effectiveness of therapeutic interventions of 35 medical doctors at level Psy-3 with 135 patients and demonstrated significant clinical improvement with regard to different aspects of psychosocial burden as measured by SCL90R, IIP-C, ADS-L and STAI-G after treatment, and even more so half a year later [6] . A third research project aimed to explore In this year’s opening editorial, Fava et al. [1] introduced the ‘biopsychosocial factor’. They referred to George Engel’s publication [2] in Science on the need for a new medical model and pointed to the ‘dangerous’ parts of this paper. These parts deal with Engel’s remarks on the significance of commercial interests in medicine, the impact of a decline of clinical observation, and the clinical inadequacy of the concept of disease. In this context, in accordance with Tinetti and Fried [3] , Fava et al. argued that clinical decision-making for all patients should be addressed to the attainment of individual goals and the identification and treatment of all modifiable factors, including non-biological ones, rather than solely on the diagnosis and treatment of individual diseases. In order to provide a stimulus for a psychosomatic renewal of health care, the authors proposed the ‘biopsychosocial factor’ as a more dynamic concept than a ‘model’ implies. In addition, they pointed to novel assessment methods that could help improve the clinical process. In this contribution we aim to underline and amplify the suggestion of the biopsychosocial factor by relating it to the Austrian national health care system approach to psychosomatic medicine. This approach has developed a strong focus on postgraduate training which is open to several medical specialties. It is intended to lead to a more structured implementation of biopsychosocial medicine. It should be mentioned that the Austrian health care system is financed by public money. Additional health care services are provided by the private sector. A comparison of national health care systems suggests different ways to integrate psychosomatic medicine in medical education and clinical practice. Accordingly, in several health care systems the term ‘psychosomatic medicine’ is used with a different meaning. As in many other countries, in Austria it is primarily interpreted as a comprehensive field with relevance to most if not all medical specialties. Thus, 20 years ago, a continuing medical education programme called ‘Psy-Curricula’ has been established. This long-term programme can be attended by physicians Received: March 20, 2012 Accepted after revision: June 18, 2012 Published online: September 20, 2012