My first patient is booked for 9.30am. Katie is a 14-year-old girl referred for an urgent appointment by her GP with auditory hallucinations and suicidal thoughts. I start by getting to know her. We chat about her interests and she’s surprised at how much I know about the latest Ariana Grande gossip. We speak about her friends, her enemies, how disappointed she is in her lacklustre number of followers on Instagram (I reassure her that she has more followers than I have ever had). We get into the meatier stuff – the acrimonious divorce of her parents and the domestic violence she has witnessed in her home, the bullying that occurs in the school yard, the despair about her uncle’s suicide last year. I determine that the ‘voices’ are in fact her own negative thoughts and she has no signs of psychosis. I meet with her mother and assess her level of risk as low enough to safely allow outpatient treatment. We put in place a safety plan and arrange the next appointment in a week’s time to begin psychotherapy. I also make plans to speak with her school to address the bullying and write a letter back to her GP to update and thank them.
I see five more young patients in clinic that day. I’m working in an outpatient clinic at a major paediatric hospital. Each appointment is for an hour. Four of the five patients are my regular patients with whom I’m doing cognitive-behavioural therapy. The other is a new referral with trichotillomania. The vast majority of these patients, with the right supports (individual therapy, parental support, liaison with their school, engagement in social activities, support from allied health professionals, and occasionally medication), will have positive outcomes.
I finish clinic at 5.30pm and head home. I’m on call overnight. Part of the role as a psychiatry registrar involves overnight on-call. This is a demanding role, as our Emergency Department sees 90,000 patients each year. I’m in the Emergency Department from 10.30pm to 5.30am seeing three kids: one suicidal girl brought in by the cops under the Mental Health Act, another acting bizarrely with possible psychosis after taking amphetamine, and another child with autism who has become so violent and unmanageable at home that his mother is refusing to take him home and wants him admitted. Added to this, I also spend the night dealing with ward issues. I crawl into bed at 6.00am, ending a 21-hour day that involved 16 hours at work.
I chose psychiatry envisioning a good life, not a busy life. Fortunately, the day described above is atypical. Most of my days begin at 9.00am and end at 5.00pm.
My journey into psychiatry involved a roundabout path. I initially wanted to specialise in cardiology. However, after becoming disillusioned with general medicine, I took an extended break from physician training and during this time worked as a psychiatry locum. My hiatus as a locum morphed into a career change and I never went back to being a medical registrar.
In internal medicine, I had become somewhat disenchanted by a feeling that despite all of the expensive tests and interventions, there was more often than not only a marginal improvement in the quality of life of my patients. Because I had been rostered to acute medicine and ED medical nights, I rarely got to know my patients beyond their pathology. I used to think about the famous William Osler aphorism that ‘the good physician treats the disease; the great physician treats the patient who has the disease’ and pondered how modern medicine, with rapid turnover of inpatients, makes it so difficult to be a great physician.
I was drawn to psychiatry for a number of reasons.
Firstly, the treatments in psychiatry are not flash or fancy but they are effective. The biggest cause of death for Australians aged 15-44 is suicide (AIWH, 2018). With mental illness, if you can intervene early, treat the symptoms and help the patient navigate through a difficult period, you can have an indelible impact on their trajectory in life. Many medical students and junior doctors get a warped perspective of psychiatry as all they experience is the cacophony and chaos of public inpatient wards (which tend to contain individuals with treatment-resistant schizophrenia and or substance addiction and suicidal patients with borderline personality disorder). What they don’t see are the majority of patients with mental illness who have good outcomes.
Secondly, the complexity of the work means I have a lifetime ahead of learning new things. The practice of psychiatry requires an understanding of neuroscience, psychology, law, ethics and philosophy. It involves making decisions under uncertainty, without blood tests or brain imaging to guide you (although this will likely change in our lifetime).
Finally, working in psychiatry involves connecting with people at their most vulnerable. It involves showing compassion to and advocating for some of Australia’s most disadvantaged people. The work can be challenging. You are sometimes the emotional garbage bin of your patients. They thrust upon you their darkest secrets, deepest sorrows and most primal aggression, and you have to manage this. But it is hugely rewarding.
For those of you who are inclined, I strongly encourage you to do psychiatry and become a ‘great physician’.
This article discusses suicide. If you or someone you know is struggling, please seek help and call Lifeline on 13 11 14.
Anxiety with Dr Julian Nasti
Medically unexplained symptoms (MUPs) with Dr Joanne Ferguson
Psychosis with Dr Joanne Ferguson
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