Psychiatry is not merely a branch of general medicine - it has a history and present configuration that is otherwise totally unique in medicine. But in the past fifty years the scope of psychiatry has moved far beyond the old institutional basis even as it is ever more enriched by developments in general medicine. This issue surveys not the content of psychiatric sciences, but the processes by which our care for millions of suffering human beings is being dramatically reshaped, despite many setbacks, generally for the better. These diverse qualitative and technical trends range from changing models of service delivery and finance, increased focus on quality innovations in education and workforce development, telehealth and electronic records, among many others. Each and all will touch the individual practitioner and affect every component of the health system with increasing benefit to care of patients and society at large.