Canaries and Coal Mines
This year marks fifteen years of working as a consultant psychiatrist after more years of training to get there. I’ve worked in many sectors of public and private psychiatry and medicolegal practice. I worked extensively as a public sector psychiatrist through the COVID-19 pandemic, locuming through hospitals and healthcare settings in NSW and Victoria. Until I didn’t. I walked out of a role and type of work I thrived in and was really good at. Eventually, the job got to me; my last day was the one following being assaulted by a very unwell patient, and I made a decision that day to put my safety and well-being first. I have not treated a patient since.
I resonate strongly with the decisions of my NSW psychiatry colleagues about to do the same thing as me next week. In 2022, almost three years ago, I was a solitary canary in a coal mine who tried to take my concerns about ward safety and a drastic understaffing on what was a brand new psychiatric ward to management. Nobody cared. My resignation wasn’t part of a mass action, but I know of many psychiatrists who have done the same thing as me in recent years. And many more who are planning to. I can promise if my locum agency offered me double the money I was earning to stay I wouldn’t have. It wasn’t worth it.
By the time I left my last post I had started to notice huge changes in the roles locums were posted to. I had been locuming in conjunction with running a private practice across Australia since 2014. By the time I left in 2022, I noted an incremental change in daily pay rates, but a diabolical change in the amount of risk I was exposed to, and expected to work amongst and manage. This risk was combined with resentment; as I walked in for day one I was notified of all of the regular psychiatrists who had taken sick leave hearing I was coming. I was expected to cover their work. I didn’t blame the other psychiatrists who knew how much I was being paid for taking a break when they knew there would be somebody else around to work and at a much better pay rate. I resented being left with whole departments of psychiatry to cover on my own. On my last day at a huge regional hospital in Victoria, I was the admitting officer, the consultant for the acute care team, the ward psychiatrist for 27 patients who had not seen a psychiatrist for a week, and the psychiatrist for the medical and surgical patients with psychiatric problems for the entire hospital. I had no orientation and no duress alarm. I was a sitting duck.
I lasted three days and left my post early for the first time in my career. It wouldn’t have mattered how much I was being offered to work, there is no worse way to feel alive than knowing you are responsible for crises in different areas of the hospital, all of similar urgency but not able to respond. Something no Coroner or grieving family member would ever accept as an excuse if a sentinel event occurred, which was on my mind constantly. My terror, and it was terror by this stage made me drive back along the highway to home and never practice as a clinical psychiatrist again. I was still shaken from the assault the day before, and I was a seasoned experienced psychiatrist who had seen and managed a lot of emergency situations by this time.
So when I hear about the current crisis affecting NSW Health, the latest canary in the coal mine that is our fractured and sub par mental health system, I despair because I know locums aren’t the answer, and not because they cost a lot of money. It’s primarily because I know from my connections with locum agencies and talking amongst my colleagues, there just aren’t that many locums around to fill those spots that will be abandoned next week. There are already multiple posts in NSW that are unfilled and this is preceding the mass resignation. I’d be surprised if the psychiatrists resigning next week plan to jump straight into locuming for the same roles — we are not normally driven by money and it’s more likely they are motivated by a need to get away from the constant insults and obstructions to our ability to care for our patients. So I do declare, raise the locum rates but the people won’t come. We aren’t there anymore.
Over my medical career, I have had office bearer roles in doctor advocacy and industrial relations and have experience when it comes to negotiating with government ministers for pay rises and better conditions for doctors. I know Governments rarely respond to threats and if their budget can’t accommodate what is being requested, and with a reason or solution they can see and understand, they aren’t interested. It’s so disappointing that the situation in NSW has come to this, with a stand off, and media grabs that are not explaining the predicament, causing panic and division amongst our colleagues and our patients. I don’t think the situation can be reduced to, pay us what we deserve rather than pay locums. The government has already declared it does not value what psychiatrists do and would not rather pay any psychiatrist, locum or permanent, anymore. I am sure they have not worked out how to fund a locum workforce by next week. Meanwhile, staff psychiatrists will walk away from accruing long service leave, annual leave, and thousands of dollars for continuing medical education, benefits that have kept doctors in the public system for years, and not available in the private sector unless it is self-funded. And that will benefit the government who will escape funding these entitlements en masse.
I am also very despairing for the psychiatry trainees who are hearing about this stand-off and crisis like me, through the media. They are about to start a new training year in February and will be asked to step up and act out of their roles by a government that doesn’t understand what they do and what they are capable of doing. In simple terms, trainees are just that — extremely competent and talented, but training to be consultants. They have invested months or years of training time, at salaries way below that of a consultant psychiatrist and have spent thousands of dollars to sit exams, sometimes on more than one occasion. When I was in their predicament, and I often was in posts with little or no supervision through my training time, I was constantly fearful something would go pear-shaped on my watch and I’d be the scapegoat. To know that wasn’t something unique to a period of my training time, or a post, but the new norm, I’d probably be reconsidering my career choice. Compounding this is that they train in an environment where it is way too easy to complain, to launch an AHPRA investigation or to be scapegoated by hospitals covering up major systemic issues. And unless the NSW government plans to make drastic changes to the Mental Health Act by next week, they won’t be able to carry out the work anyway, unless they are prepared to fill out Mental Health Act paperwork illegally and answer to a Mental Health Tribunal who would, quite rightly, buy none of it.
The debate about why psychiatrists are irreplaceable seems to be a perennial one, at least for as long as I have been working in psychiatry, and that’s nearly 25 years. I don’t know of any other medical specialty that keeps having to justify its existence. I took a role in a primary health network about 10 years ago and my sole brief was to map out how the network could do everything they did without having to use a psychiatrist. I left shortly after starting. It continues to rub me up the wrong way that every time funding is announced, a new digital app, a new service model, a new change to the way things are done, the psychiatrist in the team is never considered valuable. Nurse managers and managers in general run mental health services, not us. I’m guessing to be so devalued for our clinical experience and skills, for such a long time, during an ongoing mental health crisis and surviving a pandemic has been a bigger motivator to the decision for many psychiatrists to walk next week and not their salary.
So speaking of money, should the psychiatrists get what they want at the 11th hour, will that change how they feel about working in the public system and will this flow on to an improvement in patient outcomes or a better quality health care system? It is impossible to compare how the public sector psychiatry workforce, or any medical workforce is funded across different states in Australia with NSW. Some states simply offer incentives for psychiatrists to work where there is a greater proportion of rural and remote areas such as Western Australia, who never operate with a full complement of psychiatrists regardless of how much money they offer.
It seems that talks have stalled between the psychiatrists who have taken a stand and the government that pays them. I don’t see that changing, as the NSW State Government calls their bluff, but again, I only hear about this like everybody else, and that is through the media. I can’t imagine NSW psychiatrists will be packing up themselves and their families next week to move to WA or the Northern Territory where they can earn more money, although I know they would be received with open arms. I fear that the result of this standoff will be, as with so many other times, the canaries will get released and the coal mines will continue to function, with statements from management and spin for the media to call helplines if in crisis. And that will be to the detriment of our valuable workforce which is more finite and unsustainable than ever before, our training psychiatrists and the community that we serve.
Dr Helen Schultz is a consultant psychiatrist, a coach and mentor to RANZCP psychiatry trainees, and a professional writer and media authority. She can be found here on Linkedin, and for all media inquiries at helen@drhelenschultz.com.au
