Ready to take on the wellness warriors?

Greetings all,

5 days to go until the early bird registration ends for MedicineSocial, and such a pertinent time to reflect on why doctors and other thought leaders in health must embrace social media for good.

We all have our degrees, expertise and experience in our particular crafts. We believe that because patients come to see us they take on board what we have to say as the truth. In many situations, this is the case. In my craft, psychiatry, this may not always be the case.

How many of you ask your patients what they think might be wrong with them or if they have researched their symptoms, or even you on sites such as Google before attending the appointment? Increasingly. the answer is yes. And that is OK if it means patients are trying to learn as much as they can about how to manage their illness, or believe they may not have one.

But the opposite may be true. For example, despite global campaigns and public health messages about vaccination, the majority of information on social media may actually attract parents to anti-vaccination lobbyists.  Known as keyboard warriors, these people despite different motivations spend a great deal of their day uploading content that is ill-founded but plays upon the vulnerabilities of new parents. Sometimes they can play dirty. Often they use motivations such as fear and shame to endorse their message. What they are good at is knowing how to drown out a debate regardless of truth by saturating common search engines and staying on message.

And then there are those with the ‘quick fixes’. Once again a varied bunch who may actually believe they are onto the right thing. At least 2 or 3 times a week, I am asked by patients if I have heard of a recent cure for schizophrenia or anxiety. Not because they don’t believe in their care, they simply hope that there could be something more benign than the potent medications we prescribe with sub-optimal efficacy. Recently, I told a patient that if I believed high doses of folinic acid cured anxiety I would be the first to promote it. I don’t like prescribing medications with intolerable side effects but I also don’t like seeing patients suffer from severe mental illness.

What enrages us all is those who don’t have any training in health, who deceive the public for overt secondary gain (financial) and delay others from getting help until it’s too late. Recent ‘wellness warriors’ have been vilified for this, and at times been excused for having a mental illness. In particular, these warriors are said to have Munchausen’s syndrome.

Now, Munchausen’s syndrome is extremely rare and involves the development of the sick role to foster care, nurturing and attention. That is the secondary gain. We see this in extremely traumatised individuals who perhaps have not been cared for in childhood years, or even abused. Their behaviour is conscious but the gain is to keep people close.

What I fear is those who do not have Munchausen’s syndrome may be seen to have it without a clear understanding of the true definition. Again, the behaviour is conscious but the secondary gain is fame and financial. This is called fraud or malingering.

Why do patients then fall for these claims and not listen to health professionals? Because the perpetrators of the claims are very good at manipulating basic human behaviour. For example, if you were faced with a blizzard and had to go the to supermarket, would you walk or drive? You would weigh up the quickest, most appealing option, and if the correct amount of spin was placed on this option you would take it.

What doctors and health professionals don’t understand is that we no longer live in a world where many accept medical advice with a degree of scepticism and inquiry. That’s understandable when information is so readily available. But what we have to do is be as savvy as the wellness warriors and campaigners, deliver our messages unique to our craft and fight fair. Because if we are left behind, patients will work with what they have and our crucial evidenced based public health messages will be diluted by the snake oil merchants.

Dr Helen Schultz is a consultant psychiatrist and blogger in Melbourne, Australia. She has organised Medicine Social to educate and inform doctors and health professionals about the importance of being a leader in social media and medicine. 

DiT Forum at AMA house on Thursday 5th March 2015.

Greetings all,

In light of recent deaths amongst our Victorian DiTs, a small working party has formed, and a decision has been made to hold a forum on Thursday 5th March 2015 at 7pm at AMA House, Parkville.

This is short notice but it was decided that it would be prudent to hold the meeting sooner rather than later as we are aware of impending examination timetables.

I am involved because I was a DiT not long ago, used to be a president of the AMA(Vic) DiT subdivison and around when there were some suicides amongst our friends about 10 years ago. What came of similar forums was the establishment of the AMA peer support service.

I have never shied away from being outspoken and an advocate for all DiTs including medical students. DiTs are a large, invaluable, resourceful and caring group of the medical profession.

DiT’s also get very bogged down in making to the ‘ticket’. They work hard and endure a lot to get good reports and pass exams.

Despite being a large group of the medical workforce DiTs can feel alone.

I have been vocal recently about what I do know. 4 DiT’s including 3 psychiatry registrars are no longer with us. There is and probably will always be conjecture and a lack of understanding about why they are no longer with us. These deaths may be unrelated or there may be a factor that ties more than one.

We don’t know unless we start talking. 

And even if we do not know, we may be able to use this tragedy, and it is a tragedy, to regroup so trainees can tell those that want to listen exactly how it is to be a DiT nowadays.

We may uncover that other DiTs working in the 4 sites where they lost colleagues are not coping with the news. They may be struggling too. There may be systemic or their may be local issues.This is not about blame, it’s about guiding future discussions that hopefully will implement real change.

AMA (Victoria) and its senior officebearers, including the current AMA(Victoria) president, Dr Tony Bartone, and past presidents have stepped up to hear about this from the time we all heard about the deaths of 4 DiT’s since January 2015.

AMA(Victoria) have kindly offered to host the meeting and provide facilitators to assist the discussion.

I will be there because I want to know as well.

It’s Ok to say if you are not coping, or if you can see others not coping.

Please attend, regardless of your involvement in the passing of 4 DiT’s and especially if you are affected by the news. You do not have to be an AMA member to attend.

RSVP here

Please see your GP, or contact the Victorian Doctors Health Program via AMA(Victoria) if you need more formal support.

See you Thursday,

Helen

Supervision versus mentorship What we don’t learn in medical school, but find out from the school of life.

I was a pretty outspoken registrar during my psychiatry training. That’s a comment that has been levelled at me many times. Along with the one about caring ‘too much’. Self-reflection revealed that this was a combination of being passionate, as well as trying to transition from a life where I worked as a pharmacist to one of a medical student. I was older than many of my peers and also some of my ‘seniors’ which proved very difficult for me. In addition, I had worked in very senior roles and did not quite fit the paternalistic mould of master and student. And I knew that although I knew a lot about pharmacy, I had a load to learn about medicine.

Because of these reasons, I recognised early that if I was going to succeed at being a doctor I would have to go out and find some like-minded individuals to get the support I needed.  I needed mentors to guide me to and beyond training years. I needed this as importantly as my professional training

And then I was accepted into psychiatry training. A large part of my training occurred on the job and in lecture theatres but also as part of what I would come to know as supervision. Peers training in other specialities regard psychiatrists to have a layer of support they might not have because of this formal component to psychiatry training known as supervision. This article reveals my impression regarding why this is often not the case, what can go well and not so well in supervision, and above all else, why one mustn’t confuse supervision with mentorship.

Supervision in psychiatry is as old as psychiatry itself. But it was never designed for support. Classical supervision would occur behind closed doors and be a vehicle for further exploration of what Freud described as the ‘transference’, that is, the dynamics of the interaction between patient and therapist. In these early times, supervision allowed another psychiatrist, aka the ‘supervisor’ to interpret and analyse the treating psychiatrists’ feelings about the case, and the dynamics at play between the treating psychiatrist and their patient. The supervisor was kind of like a fly on the wall in the therapy session yet a on a wall down the corridor and about 2 days later. Maybe a Venn diagram would help explain this dynamic as well. It’s tricky.

Yes, so much of early psychiatric diagnosis and even today is about interpretation of what is said and the way it is said by the patient. Having a supervisor in modern times is still based on these foundations. When you are primarily involved in the care of a patient, ie a consultant psychiatrist, you seek out a supervisor to discuss complex cases. Such as patients that don’t seem to be responding, challenge what else you can try, and explore why you feel a certain way about a patient and how they respond to you. (I am hoping Freud is looking down on me and ensuring I have this correct).

The reason I labour this is because supervision in the strictest sense is not about your stuff. It is not about how you are, what is annoying you this week, and how your own personal life interplays with professional duties. These more personal conversations occur between a person who just happens to be a psychiatrist and a mentor.

And then there is the role of a supervisor during psychiatry training, as set out by the training college for all registrars, the RANZCP. As part of training, registrars move sites and roles ever 3-6 months and are lucky (or unlucky as I will explain) to have the same role for a year. Each time they are rotated through, they get to meet their new supervisor who is invariably their consultant, ie, boss. Their direct report, the one who hopefully engages in meaningful bedside teaching, dispels some myths about psychiatry and shares anecdotes over coffee in the hospital cafeteria. These supervisors may be swamped by all the forms they need to fill out about your progress, which is given to the college of psychiatrists, and they may be good or not so good at giving feedback. They are often busy consultant psychiatrists who juggle public and private practice work, their own lives, hospital administration and whatever else. They may have all the time in the world for you, or they may encroach on your dedicated supervision session times (which should be protected) because they are consumed by the tasks of service provision. No matter what, however, by the time you work out what they are like, it will be time to move to the next rotation.

This is important to note because it is a trap for young players to presume the role of supervisor before getting feedback about how they see and perform their role. They may be somebody you see only once a week, they might be very hands on, or they might not have a lot of time to teach you. They may not be the best people to tell if you are struggling as they are also the ones that fill in your progress reports.

Don’t get me wrong. I have some outstanding colleagues and friends in my life whom I aspire to be like and would never have met if it wasn’t for the fact that fate sent me to a rotation where they would be waiting for me. But the key is, you need time to work out which ones these are. This takes time and experience. Just as Freud would sit back and observe, we also need to do the same with our supervisors. And then make considered decisions about what we disclose and what we leave for others.

In some cases, clashes can occur between supervisor and registrar and during these times it is very hard to identify a mediator. Often it’s about waiting out the rotation, hoping that the feedback isn’t too harsh and trying to move on. I have been on occasion quite vulnerable in some supervision sessions that have occurred behind closed doors. What made it worse was that I discovered I wasn’t the only registrar to feel that way with that particular supervisor. But sadly, nothing often changes and registrars do rely on the ‘get out’ clause of the weeks ticking by till the next move.

Supervisors also have a role to play in protecting the public and reporting up if they feel a registrar is impaired. This is an extremely difficult situation for everybody not least the supervisor who is concerned. Often systems are bad at handling these situations. Often the people most in need of support find it lacking. At the pointy end, some supervisors without adequate support themselves may fall into a role of trying to treat the registrar as if they were a patient, or somebody to rescue. These blurring of boundaries can lead to harm, they can happen insidiously and cause devastating outcomes.

So hence, my advice is to find mentors. Mentors can be absolutely anybody within and without medicine. In this era of social media I now have mentors I have never met in real life, who send me private messages and make me feel connected at times of vulnerability. Some mentors come and go, often to plant knowledge and wisdom within you that you will share with others over time.

My wonderful example of this was a lovely medical registrar who was working on night shift alongside me when I was a frightened resident, sleep deprived and about to throw my never ending buzzing pager at the wall. It was about 5.30am on the fifth night of night shift in a row and it felt like time had stood still. As often happens in the early hours of the morning, multiple patients experience cardiac and respiratory symptoms requiring urgent attention all at the same time. Unless you have experienced it, it is hard to comprehend how surreal the combination of sleep deprivation and terror really feels.

So as we were sorting out the latest complex case (well he was sorting out and I was doing what I was told), he looked over at me, must have recognised I was in that crazy sleep deprived/terrified/surreal state and said

“You know, they can hurt us but they can’t stop the clock”

In that moment I knew he got me. He got the sheer frustration of a system that makes you work in such difficult circumstances and he was reassuring me that it would end. Because I had forgotten that at some point I would go home to reality.

That person became my hero and my mentor for the rest of the nights I was on duty.

So in summary, when thinking about supervision and mentorship, perhaps have a think about the following:

  • Just because psychiatry registrars have supervision does not mean they have support, or are more resilient than other folks in medicine. In psychiatry, the concept of supervision is much more complex than this.
  • Nobody teaches you how to work out which supervisor you will tell what to, that’s up to you to discern. In the meantime, form your own opinion.
  • Sit back a lot and work out why you have chosen certain people in your career that you want to aspire to be like in medicine.
  • Tap those same people on the shoulder and ask if you can meet with them for a coffee sometime
  • Have the utmost respect for anybody who comes along after you that you may mentor, and needs help working out who they trust and respect as well. Work out which camp you are in. Declare your conflicts of interest up front so they can work out how to relate to you. If you are supervising and having a direct impact on their progress through training, perhaps you just aren’t the best person to be a mentor. But maybe, when that conflict has disappeared and the registrar has moved on, you can be.

Dr Helen Schultz is a consultant psychiatrist and mentor of doctors in training. She wrote about her experiences as a psychiatry registrar in her new book, How Shrinks Think. She was recently a part of Radio Nationals Background Briefing documentary regarding doctors in distress. Helen loves being a mentor but it has to involve good coffee.

Mandatory reporting and doctor’s health. Friend or foe. ABC Background briefing today.

I have taken part in a documentary on ABC RN Background Briefing today, and I will write more posts to follow. A compelling, confronting discussion about the constant concerns of doctor’s health, the factors at play, and raw accounts of the effects of completed suicides on partners, families, colleagues and patients. Particular reference was made to the impact of recent laws around mandatory reporting as set down by the national regulatory body, AHPRA.

Well done to Ann Arnold for an amazing documentary. She has put together a depth and breadth of opinion from key people either directly affected or in leadership roles within the medical community.

My hope is that this discussion continues out of respect for the recent tragic loss of 4 colleagues in Victoria, for those that we don’t know about or those that can be prevented if the correct help is provided in a caring, professional and confidential manner.

My next post will be about the role of supervision and mentorship, and why they can’t be seen as the same thing.

Helen