Time for a change

When I coach psychiatry trainees for the RANZCP essay exams, I emphasize the importance of considering what the examiner reads when marking their essays, not what they plan to say.

Often, gaps in communication occur here, leading to the wrong message landing or inadvertent or incorrect beliefs being conveyed to those who are listening and responding.

It does really feel that despite all the advocacy from the NSW psychiatry workforce about the value and expertise only consultant psychiatrists can offer, what the government is hearing is that psychiatrists only care about money and that money could be spent elsewhere, including on a temporary locum workforce.

I remain very concerned about the plight of psychiatry trainees walking into our public psychiatry wards next week with little direct supervision. They will also be rostered to placements with bed closures due to the lack of psychiatrists, wasting valuable resources, skills and manpower at a time when that couldn’t be more needed. And there has been no direction from the stakeholders about contingency plans for this.

I am also very concerned about what our psychiatry trainees are reading and hearing when they follow along with the updates of the NSW mass resignation of psychiatrists, which has begun in force. I am concerned that psychiatry trainees are hearing and now believing that the medical specialty of psychiatry is redundant, best suited to the input of non-doctors, and a surefire trajectory to burnout, demoralisation, and serious safety breaches.

While psychiatrists have spoken in unison about the decimated mental health setting, one not fit for purpose, but also the only setting that first-year psychiatry trainees are rostered to, many enthusiastic and passionate trainees may be re-evaluating their decision to dedicate their medical career to becoming a psychiatrist.

A lot has been spoken about the fear the industrial relations actions have created in those who rely on the system for treatment, support and care. Vulnerable patients who already know how difficult it is to access care in crisis are reeling now, especially if they reside in NSW, with alerts issued by NSW Health similar to what they were publishing during the COVID-19 pandemic. But maybe the fear is also ever-present in the trainees about to start work next week.

It is time to think about what trainees might be feeling right now as they finish up their resident placements this week and prepare for the life of a registrar, who won’t have the access to the consultant psychiatrist teaching and supervision they must be able to access to work safely.

When reflecting on my career, I can see that my clinical expertise came from working in a wide range of settings, and in many geographical locations in Australia and the UK. I can look back with hindsight and be reassured that all of the experiences, good or not so good, helped shape my career as a consultant psychiatrist. I know that my decision to pursue psychiatry as the only field I wanted to work in was the right one for me. I wonder if I would have felt the same if the landscape was what it is now, post-pandemic, and with critical shortages of medical and allied health professionals.

I am also hearing the message that the private psychiatry system is the best place to work currently if you are a psychiatrist determined to be supported and remunerated well. It’s where the NSW government are attempting to access beds for inpatient admissions, now that whole wards are closed. It’s also the place that is not staffed by psychiatry trainees as a whole, and especially not in the first few years of their training.

Working exclusively in the public mental health system in the first few years of training ensures that trainees gain a lot of experience in what we call low-prevalence disorders; those that are less prevalent but more complex, such as schizophrenia. Patients with low-prevalence disorders do deserve best-practice care, but leaving trainees in these workplaces currently will mean little or no access to the diagnosis and management of disorders such as depression, anxiety and many other psychiatric conditions that are seen more frequently. They will also find their supervisors are moving to the private system, along with the patients who can access private psychiatric beds.

The argument to allow psychiatry trainees to work in more diverse settings is a perennial issue that goes nowhere, probably because they are indeed the workhorses of the public system, and psychiatrists often choose not to work there once they become consultants. They earn way less than a consultant psychiatrist, and keeping them chained to these roles ensures the system gets a lot of input for much less money.

Maybe this time of crisis may be a time to change how we do things, for doctors and patients alike.

Listening to what psychiatrists have been saying about giving our trainees the best experiences and learning possible by allowing more training places in the private system may have never been such an important message to hear. Perhaps it is time to move trainees out of the public wards if they are not safe there anyway, and our Governments believe they can amend the skills shortage by using non-medical staff. Keep them with their psychiatrist supervisors, enhance their training experience and leave the NSW Government to sort out the workforce until it is safe to return.

Dr Helen Schultz is a consultant psychiatrist based in Melbourne, Australia. She is a tireless and longstanding advocate for doctors and a coach and mentor to doctors-in-training.

More here: www.drhelenschultz.com.au