A Conversation About… Emergency Psychiatry – Part 3

Disclaimer: The following transcript has been autogenerated and may contain occasional errors or inaccuracies resulting from the automated transcription process.

Host (00:01):

Hi there. Welcome to Mental Health Professionals Network podcast series MHPN’s aim is to promote and celebrate interdisciplinary collaborative mental health care.

Professor Mark Creamer (00:18):

Hello and welcome to this episode of MHPN Presents A Conversation About. My name’s Mark, Mark Creamer. I’m a clinical psychologist and a professorial fellow in the department of Psychiatry at the University of Melbourne. My specialty is actually the mental health effects of trauma, but I’m also very interested in emergency mental health. I work for many years in public sector psychiatry, and so it’s been a real pleasure for me to host this three-episode series in which we’ve been exploring several aspects of emergency mental health. This is the final episode in the series. In the first episode, I was joined by Dr. Song Chan, and we chatted about how to deescalate mental health crises. In the second episode, Dr. Tad Tietze, and I discussed how to manage someone who is suicidal. But in this final episode, we’re gonna talk about how to recognise and respond to de distress and anxiety in our peers and indeed in ourselves. And I’m delighted today to be joined by not one but two experts in the field of emergency psychiatry and emergency medicine. Dr. Jacqueline Huber is a staff specialist psychiatrist at St. Vincent’s Hospital in Sydney, and the clinical lead for psychiatry in the emergency department and in the psychiatric emergency care centre. And that’s among a whole lot of other roles. Welcome Jacqui, thanks very much for joining us.

Dr Jacqueline Huber (01:38):

Thanks Mark. It’s great to be here.

Professor Mark Creamer (01:39):

And Dr. Clare Skinner is president of the Australasian College for Emergency Medicine. She’s a senior staff specialist in emergency medicine at Hornsby Ku-ring-gai Hospital in Sydney, and she tells me that she’s on more than a gazillion committees. So, I’m thrilled that you’ve been able to find the time to join us today. Clare, welcome.

Dr Clare Skinner (01:57):

Thanks, Mark. What a lovely break from being on a committee.

Professor Mark Creamer (01:59):

Yes, quite now, both Clare and Jacqui are passionate about emergency psychiatry and emergency medicine. So they are, ideally suited to be discussing this topic today about how we recognise and respond when our colleagues are perhaps struggling. They’re not travelling too well in the context of our work. So again, it’s a warm welcome to you both. In our previous episodes we talked about the fact that for most clinicians, these are very difficult, challenging situations. And in both episodes, I’ve said I’m certainly one of those. These are not situations, these mental health crises dealing with actively suicidal people, these high stress situations, they’re not something that I must say I look forward to and I don’t think many clinicians do. So, I’m really fascinated to hear from both of you about your experiences and about how you’ve become so interested in what is such a very difficult area. So, Jacqui, let’s start with you. What got you involved and interested and committed to this particular area?

Dr Jacqueline Huber (02:55):

Yeah, thanks Mark. Well, as you’ve said, I’m a psychiatrist working in the ED and a mental health crisis unit. And I should say I’m probably a bit overly enthusiastic about this work. You know, I like connecting with people, but in honesty, the way it gets my heart pumping and also it’s natural meaning other things that really excite me about the things what I do, but also I’m the clinical lead of those teams and I got really interested in staff wellbeing. When I saw how much of a difference leadership style makes in setting the wellbeing of the whole team, I’ve noticed that the way I manage myself and the wellbeing of the people around me kind of impacts the temperature of the whole system. And I realised this is a scary area to like bring to consciousness for us, but it’ll only be more scary if we don’t talk about it.

Professor Mark Creamer (03:40):

Yeah, absolutely. So, it’s really an important part of your role quite clearly. Let me perhaps turn to you, Clare. Now you are a specialist in emergency medicine, not actually in mental health, but you are clearly passionate about the psychological wellbeing of people who work in these kinds of settings. What got you interested in that aspect?

Dr Clare Skinner (03:58):

Look, Mark, I’ve always had an interest in education and an interest in communication skills. And my experience there is that difficult conversations only get more difficult the more you leave them. So, I decided to actively lean into something I perceived as being very difficult as a clinician, but also something that is very difficult for the clinicians who do it. Mental health is a very large part of what we do in emergency departments. We’ve been slow to acknowledge that that’s part of our work. And I think we are developing our skills and are interested in that. It’s fairly new for me and my colleagues. It’s really traumatising to be around people at their worst moment. My own experience is that if you do this well, and a lot of doing this well is actually not hard. It’s actually just making yourself vulnerable and human. And you have these difficult conversations and you have them in a really good open way that’s better for patients, but it’s also better for you as a clinician because then you actually come away feeling a sense of satisfaction and engagement with someone and you could provide them with a far better clinical experience than they might have had. And that actually makes you feel better as a clinician too.

Professor Mark Creamer (05:00):

And I’m interested, your comment there, you didn’t say this, but let me twist your words, that you really weren’t trained very well to deal with psychiatric emergencies in terms of your role as an emergency physician or emergency medicine. Is that right? That it wasn’t part of your training?

Dr Clare Skinner (05:12):

No, I think we do receive training in this, but we receive training only in the very pointy end. And I think people are scared of emergency mental health and I think it doesn’t take much training or much experience to start to get more comfortable with it. And I know that often people approach the emergency department in crisis, but sometimes all they need is to receive human care. And I hope that when they receive that care, they learn to trust us and then they’ll seek ongoing involvement with the health service. So, I see us as the concierge of the health service, so it’s very important that we provide a warm experience and a warm referral.

Professor Mark Creamer (05:44):

Absolutely. And that’s so crucial, isn’t it? Kind of opening the door and making it possible for people then to have a care pathway that’s gonna suit them. Perhaps if I can turn to you, Jacqui, and, and Clare, I’m just assuming you’re gonna jump in with words of wisdom whenever you like, but I wanna take you back, Jacqui, to what you just said, which was about leadership and perhaps expand on that. And I’m wondering about how important you think that organisational culture more generally or including leadership is important in, I guess, maintaining psychological health and wellbeing in our clinical staff.

Dr Jacqueline Huber (06:15):

Yeah, I have a lot to say about this. Interrupt me if I’m rambling too much. But I think what we’re aiming for is this concept of psychological safety. And the way of getting there, I think as a clinician and leader is to set the tone through one’s behaviour. The first thing on the list for me is to try to talk with respect about everyone around us. And that includes people who are above and below us on the hierarchy. We know that medicine is a very hierarchical system and that could be really hard. So, you’ve got first responders listening here. People might find it a surprise to hear that first responder teams and ED mental health teams don’t necessarily always get along. It’s a very high emotion experience. Teams have competing priorities. There’s gonna be conflict and conflict is okay. In fact, I would say conflict is necessary, but it’s not okay if in the midst of that conflict, you’re rolling your eyes, you’re denigrating another team to your colleagues.

(07:14):

If you do these things repeatedly and consistently, the people around you will pick that up and run with it. And before you know it, you’ve got a broken system. One has to aim to be as respectful and empathetic to all the people around you as you possibly can, noting of course that we can’t always be that way, but most of the time is good enough. In that context, given that we can’t be perfect all the time, we also have to be open to admitting fallibility. We can’t always necessarily be respectful and boundaried and calm. We don’t always know what to do. We can’t always get those clinical decisions. Right. And if we admit mistakes to the people around us as leaders, it will increase the likelihood that they will feel comfortable admitting their mistakes and discussing it openly and without judgement.

Professor Mark Creamer (08:00):

Absolutely. So that you’re creating a culture of safety in which it’s, as you say, okay, to acknowledge that you don’t know all the answers, you can’t always be right.

Dr Clare Skinner (08:07):

Precisely. Jacqui, I really agree with you about psychological safety. And from years of working in emergency departments, I know that we can’t provide good mental health care to consumers and to their carers unless we’re working as a team. And being part of a team does involve knowing how to manage conflict in a constructive way. It’s really difficult. I personally hate that game, which is it’s your patient. No, it’s your patient. No, it’s your patient. And I absolutely know that whilst the emergency department has magic plastic curtains, that behaviour is absolutely in earshot of and visibly apparent to the patients who are the reason we’re all there. So, I think disagreement is necessary. We discover things about ourselves and about patients and about the system through disagreement, but we have to negotiate that in a way that is fair and is reasonable and is absolutely patient-centered all the time.

Professor Mark Creamer (08:56):

Absolutely. One of the areas that I work in a lot is military and veteran populations. And the analogy there with military units and so on, team cohesion and leadership are so important in terms of optimising psychological adjustment.

Dr Clare Skinner (09:10):

Another thing in the emergency mental health space is, is very little objective information. We’re dealing with stories, we’re dealing with narrative, we’re dealing with direct histories and collateral histories and it, I get really upset when I see people saying, oh right, you are right. I heard this, you heard this. Because histories change and stories evolve. So, I think more than ever in the emergency mental health space, we need to be aware that different people are getting different parts of the story and bring different experiences and insights to the table. And we must respect that and put that into our systems.

Dr Jacqueline Huber (09:42):

I’m afraid I’ve got more to say. Is that all right <laugh>?

Professor Mark Creamer (09:44):

Oh, please do you just go for it.

Dr Jacqueline Huber (09:46):

Yeah, I also wanted to bring up the concept of boundaries, which I think are absolutely central to maintaining a psychologically safe workplace. I think most of the people listening to this will find themselves to be people pleasers. I know that I am. otherwise I don’t, me too. Yeah, <laugh>. I don’t think we’d be particularly good at our job if we weren’t. Like I love a good pat on the head like, good job Jacqui, you’re doing awesome, good little psychiatrist. I love it. It keeps me going. But it can lead us to be constantly breaking our own boundaries in order to please people. So, we’re like, do you need me to stay late? No problem. I’ll just finish with this patient. So, I’ll spend an extra half hour. Yep, no problem. I can do it. But what happens in the end is that you get tired and when you get tired you get resentful. And that’s a problem. It leads to burnout. In fact, we have like a superpower as people pleasers. We can see what people want and we are really talented at giving people what they want. But then the outcome is that we have this terrible anxiety about saying no.

Professor Mark Creamer (10:43):

Well, no, I was just gonna say, I mean, I agree absolutely about the importance of boundaries, but I’m also struck that perhaps at the moment where the system is under enormous pressure, I think probably in every state, it does make it more difficult, doesn’t it? To be strict about those boundaries.

Dr Jacqueline Huber (10:59):

That’s absolutely right though. If we can notice the things that we can do and then the things that are out of our control, it’s easier to identify where precisely the boundary is, but also on a deeper level to notice why we’re having trouble saying no. Is it that we don’t wanna be disliked? Is it that we think that by saying no, it makes us incompetent or imperfect or potentially just average, and we don’t wanna be just average. Without noticing the reason We’re not saying no, it’s very difficult to stop. So, we really need to be honest with ourselves.

Dr Clare Skinner (11:34):

I’ve been thinking on this a lot as well, and I think definitely most emergency doctors and probably all doctors, like external validation, as you said, Jacqui, where people please us. But I think it goes beyond that. We’re all people who spent decades in training trying to get high marks and you know, win awards.

(11:49):

We need external validation. I think we’re really good at transference and countertransference in the patient population we serve, but not necessarily when they’re triggering us. And I think your point about boundaries is really important. I also like to think about values and how they drive my clinical work and the work of the team, but I think we don’t recognise violations because actually we are so trained to chase those external rewards that we don’t realise when actually we’re chasing a sun cause and that maybe someone else would be better placed in that clinical interaction.

Dr Jacqueline Huber (12:20):

Firmly agree with that.

Professor Mark Creamer (12:21):

Sometimes it’s perhaps difficult to work out when it’s us that’s not coping because we are weak or whatever, and how much it’s actually a function of the system and the demands placed upon us and so on.

Dr Clare Skinner (12:31):

Also, in, as we talked about in in a system that’s facing widespread workforce shortages when we are not actually the right clinician either because of our skillset or because of our own psychological needs or projections.

Dr Jacqueline Huber (12:41):

Yep. And I think if all of this can possibly be modelled by a leader, it’s much more likely that the whole team will feel psychologically safe because they take their cues from their leader. So, if you as a leader can’t notice why you are saying yes to everything, can’t notice why you’re staying late, can’t notice why you won’t, as Clare says, passed this off onto someone more specialised, then your team won’t either.

Professor Mark Creamer (13:03):

And of course, that’s something that applies across the board way beyond emergency. Indeed, medicine generally that good leadership is crucial. Again, in the military, I think is crucial. And I was struck what you, you mentioned the term, or you mentioned the word control, Jacqui, which again, I think is really important that people feel in control. If we think about the literature on organisational stress more generally, it is things like feeling in control or the, the demands that are on you or role clarity or team cohesion. These things kind of appear consistently in the literature right across organisational settings. But I think in the situations that you two are working in, it’s even more important, isn’t it, to feel that you’re in control.

Dr Clare Skinner (13:41):

It’s tricky in the emergency department environment because I actually think a lot of us are used to the feeling of being slightly out of control. And in fact, we have a degree of learned helplessness. Finding or developing or massaging, chaos out of control is actually probably the key task of an emergency physician. We’d like the diagnostic uncertainty; we’d like the human environment we’re in. I chose emergency medicine because I love meeting people and I love their stories and the, the human interaction of it, but that comes with that level of risk and uncertainty, which is probably why I actively chose it. So, it’s tricky. That control thing is tricky, and you need to make sure you know, you have a locus of control within yourself, around your own values and boundaries. I agree with Jacqui on those points.

(14:17):

I think to make it concrete, I mean again, in the ED, I realise all your listeners don’t work in emergency departments, but for me a concrete example would be, why can’t you create a bed? This person has been sitting in ED for a very extended period. Why can’t you create a bed? Creating a bed is absolutely beyond my control. <laugh> demonstrably beyond my control, or I’d find you all the beds. So instead to recognise together that that’s beyond the control of the two of you, as you stand here having this conversation, but let’s identify the things that we can do within the emergency department space. We can do this non-pharmacological intervention. We can sit down and offer for validation; we can allow the person to leave or something like that. Something that you can control, and it’ll bring you both down, make you both calm and it’ll demonstrate good communication between teams. And there you go. You go your psychologically safe workplace.

(15:04):

Absolutely. When we come together and have empathy for the constraints of both of our working environments, that’s when the best practise happens.

Professor Mark Creamer (15:11):

I can’t help thinking about, it’s a cliche and I hate cliches, but anyway, I, I love this particular cliche, changing what you can change, accepting what you can’t change, and perhaps most importantly the wisdom to know the difference. Being able to, which is exactly what you’re saying, both of you really.

Dr Clare Skinner (15:24):

Shame and blame come up when people are under stress and by shame and blame and negative motivators, they actually make people dig in and hold onto their point of view more. And so, I think, you know, for me as a leader and I was head of department for a very long time in my workplace, it was absolutely about modelling. When there’s a disagreement or there’s friction between services, you actively invite the other team into your space, and you explain your constraints and you talk about your values, and you find the common ground. And that’s harder work to do than it is to roll your eyes and huff and puff and assume that the other people are acting through malice, not through horrible, horrible service constraints. Exactly. Similar to those I experienced in my role.

Professor Mark Creamer (16:01):

Hmm, exactly. Impugning or imagining the motives of others. Something we’re all very bad at doing.

Dr Clare Skinner (16:06):

I think that you’ve gotta assume that everybody you interact with in health has a backstory. They’re all there because they wanna do the best for the patient. So I just assume that everybody I interact with is well motivated, intelligent, educated and wants to do a good job and that if things don’t come across that way, there must be a reason for it and that I go looking for that reason and talking to them about it rather than assuming the worst.

Professor Mark Creamer (16:26):

So, I do just wanna reiterate the point that you made, Jacqui, by no means all our listeners are gonna be working in these emergency sharp end settings, but all of what we’re talking about I think applies across a whole broad range of settings. So, we must remember that.

(16:39):

But look, the fact is prevention is better than cure, but we can’t always prevent it. Even if we do have wonderful cultures as best, we can and great leadership and so on. So, the fact is, I guess that some of us, some clinicians will be affected by the pressures of mental health crises and psychiatric emergencies and so on. And I, I wonder if I could turn to you, Clare, and just ask if you’ve got any ideas about what you think the warning signs are, the kind of red flags that one of your colleagues is perhaps not travelling too well.

Dr Clare Skinner (17:07):

Yeah, look, thanks for that question mark. And for me the absolute number one red flag is cynicism. And that’s tricky cuz doctors can be quite cynical anyway. But when people start talking negatively about patients, when people start talking really negatively about other clinicians, I really worry that something else is going on for them. You know, I remember what it was like to be a first-year medical student and overwhelmingly the members of my year when you asked them why they were choosing to study medicine would say that’s because they wanted to help people. And so, when you start seeing people shrug their shoulders either with resignation or actively getting angry with patients, that to me is an absolute red flag that they’ve reached that level of burnout where they’re not quite seeing clearly or feeling their sense of mission that they felt when they started out.

Professor Mark Creamer (17:46):

Mm-hmm <affirmative>, does that seem right to you Jacqui?

Dr Jacqueline Huber (17:48):

Absolutely. I think we tend to rely on the more obvious signs actively expressing a wish to die, for example. And they are neglecting hygiene, but they’re extreme signs as Clare says, it’s the subtle stuff that you have trouble picking up, boredom, disinterest, trouble with empathy where they were previously like much more able to sit with someone else’s challenging emotion. Emotional outbursts are things that you might not have expected for that person or like a subtle disrespect in situations where they would usually have been amiable. Procrastinating, sometimes. So as Clare points out stuff that may just seem normal but not for them.

Dr Clare Skinner (18:27):

I actually think this gets trickier because there’s actually points where we might celebrate or promote some of this culture. Like that sort of cynical hard brick wall, you know, the brick wall in the hospital who never says yes to a console. We actively celebrate and promote some of these cultural aspects and actually don’t recognise ’em as burnout.

(18:45):

I have to admit, I also see money hunger as a manifestation of burnout in medicine where people are not getting the satisfaction from their clinical work, from their patient load so they actively start chasing money. You know, I think that’s a really cynical thing where people start going, right, I’m in this for the money and start gaming that as opposed to I’m here for the patients or I’m here for my colleagues.

Dr Jacqueline Huber (19:04):

I guess that’s a reflection of inability to continue with one’s empathy.

Dr Clare Skinner (19:07):

Yeah, so you’re chasing something that’s actually not a primary marker of job satisfaction anymore.

Professor Mark Creamer (19:12):

Yeah. Yeah. One of the things that we see a bit in the trauma field I think is people sort of becoming a bit emotionally numb and sort of withdrawing and sort of shutting out things and so on. Which I would also see as a warning sign, I guess perhaps in your area as well.

Dr Jacqueline Huber (19:27):

Absolutely.

Dr Clare Skinner (19:28):

Another big, another big warning sign we probably don’t talk about enough in medicine is alcohol culture.

Professor Mark Creamer (19:33):

Yes. And alcohol is a massive factor I think, not just in my specialty of emergency medicine, not more broadly in medicine, it’s normalised. It’s so much a part of things like our end of term celebrations, our, you know, celebration for people getting three fellowship exams. I don’t think we see the extent to which alcohol has become part of our negative culture.

(19:50):

Sure, that’s true. And as a society we spend so much time talking about a whole range of other drugs, but not often enough do we talk about the the damage that alcohol does. I quite agree. I quite agree. And I also wanted to come back quickly to something one of you said about the importance of change. That this is not what this person’s normally like that you, when you notice a change in someone that perhaps should really be ringing alarm bells for us, shouldn’t it?

Dr Jacqueline Huber (20:11):

I think that’s the central issue. If someone is generally a pretty cynical person, well you’re probably gonna continue to be cynical, but that’s exactly right. If someone suddenly starts out of nowhere to display these signs.

Dr Clare Skinner (20:23):

I also think there’s a piece here about hope for the future. Like there’s a lot we are expected to go through a lot of change management in my specialty, the breadth of knowledge you need to be an emergency physician is broad and the context change is constantly. And I know I participate in a lot of college work pretty obviously with my role, I’m very engaged with the hospital. I think when people don’t wanna get engaged in trying to improve the service or they actively start trying to suggest that you’re foolish for thinking that things could be different, that for me is another major red flag about burnout or lack of engagement.

Dr Jacqueline Huber (20:51):

That’s your learned helplessness.

Dr Clare Skinner (20:52):

Yeah. Or Stockholm syndrome.

Professor Mark Creamer (20:55):

Yes, yes, yes. Okay. In my role of constantly bringing this back to a broader population, I think for me also it highlights the importance if you are working in sole private practise in your consulting rooms, whatever the importance of having a group of peers, the importance of peer supervision, peer support, so that there are others who can pick up these signs that we might pick up in a team. But if you’re working alone, we can’t.

Dr Clare Skinner (21:16):

That’s a strength of emergency medicine I have to say, as we always work as a team.

Professor Mark Creamer (21:20):

Absolutely, yes. Yes, that is, I quite agree. But I suppose that sometimes the wheels are gonna fall off and sometimes for some people it’s all gonna get too much and they may require specialist treatment, of course they might even require an admission. And I’m wondering Jacqui, if you’ve got any thoughts about what are the implications of that for us if a colleague does require an admission?

Dr Jacqueline Huber (21:41):

So, first of all it can be useful to know that there are things that come before an admission for your listeners that are specifically tailored for clinicians, not just mental health clinicians specifically if you’re a psychiatrist, there are confidential helplines and there’s an email address associated with the college, but there’s also a collaboration between Black Dog, This Way Up and the Hand in Hand foundation that offers telehealth sessions with a clin psych or a psychiatrist as well as peer support. So, clinician peer support that puts clinicians with clinicians. If you feel yourself going downhill, there are confidential supports that you can access if you like.

Professor Mark Creamer (22:20):

Yeah. And we will make sure if we can Jacqui that we’ll put the links to those on the webpage, on the resources page for this episode.

Dr Jacqueline Huber (22:26):

Yep. But if an admission is required, it can be really intimidating for a clinician for a number of reasons. In my experience, there are two big ones. One is confidentiality because it’s a small community, everyone knows everyone, and people fear that the ir clinicians will talk. And the second is the potential for a report to AHPRA. A very intimidating prospect, understandably for clinicians. In terms of confidentiality, what we would usually do is suggest that the clinician present to a hospital that is not the one in which they work. So, it’s more likely to be confidential and again, psychologically safe. They’ll find often that they’re seen by the most senior clinician on the team and always of course kept in the strictest confidence. And then after discharge, if they, when they are eventually discharged, they’d find that their mental health would usually be managed by the crisis team from a neighbouring team rather than for their own team because they probably know the clinicians.

Professor Mark Creamer (23:26):

Sure. I wonder if we could just touch on the extremely thorny issue, which again applies to some other professions like the police, the military, the other emergency services. And that is the difficult question of, of fitness to practise I suppose. How do we manage it if we’ve got a colleague and you really have concerns about their capacity to do their job?

Dr Jacqueline Huber (23:44):

So as for clinicians, AHPRA has some very clear guidelines around who needs to be reported and who doesn’t. First of all, the, the clinician needs to be practising with an impairment that is not managed by effective controls. That might include a drug and alcohol physician being in their care or a mental health physician being in their care. And that that impairment, if it is not managed, that might be criteria to report or practising whilst intoxicated in alcohol or drugs. That doesn’t mean that the person uses alcohol or drugs outside of their work, but rather practising whilst intoxicated. Practising in a way that significantly departs from accepted professional standards engaging in or having engaged in or being at risk of engaging in sexual misconduct in connection with their practise in medicine. Also, the report needs to have a reasonable belief that the conduct occurred. So usually a direct knowledge of it, not rumours, not part of the rumour mill. The simple fact of having a mental health condition is not sufficient to make a report. Bearing in mind of course that AHPRA’s goal is ideally to help rather than punish if someone is presenting in this way.

Professor Mark Creamer (24:54):

Nevertheless, if those warning signs are there, it’s incumbent upon us not to bury our head in the sand or look the other way I guess to do something about it. Do you wanna add something there Clare?

Dr Clare Skinner (25:02):

Yeah, look, as a former head of department, I think this is a tricky aspect of medical management and I think it’s one that probably medical managers and clinical managers in general could be more supported with. I think it’s really important that you create a team culture where you’re doing regular check-ins with the people on your team so that it doesn’t feel like it’s only happening when there’s a problem. So proactively schedule regular monthly meetings in my case with all the members of the team, make sure you know what’s going on with them, make sure they feel that if they did have an issue, they could come to you and trust you. You know, this can’t be a rare occurrence. This has to be something you do actively. I really actively recommend that everyone I work with has their own GP in most cases. I think most of us are lucky to have excellent GPs.

(25:42):

Definitely in my own case, my GP has provided me with a lot of support for the work I do, and I think that’s really critical that we recommend that. And that’s also for a number of reasons, like don’t treat your family and friends. There’s a whole bunch of stuff there. There’s a lot of reasons to have your own GP. But also, I do recommend with a lot of members of my team that they have their own psychological support. So obviously there’s psychological support available to clinicians through the EAPs in their workplace and also through college. People perceive varying degrees of psychological safety with those in-house EAPs. But I’ve always maintained a list of local psychologists who are very happy to see clinicians and members of my team have used that have had that fruitful. And that’s not only for things that go wrong in the workplace or you know, anxieties about what might happen in the workplace, but also for things like training and education support and also for debrief around incidents, it’s sometimes useful to have someone who belongs solely to you where you feel you have a safe space to discuss things.

Professor Mark Creamer (26:36):

And of course, as you mentioned earlier, we need to be able to get over the shame, if you like, of having to ask for help or holding up our hands and saying we’re not travelling too well. I would like to move on though now and talk a bit about, sort of have a free ranging discussion really about what we do about it. So, let’s assume we have identified a colleague who’s not doing so well or indeed, let’s be honest, if we ourselves are not travelling too well, what do you think we should do about it? I might get you to start Clare, but what do you think are the key things we should be doing?

Dr Clare Skinner (27:03):

Like my specialty is a burnout rich specialty on all studies of burnout that have happened in Australia and internationally. Emergency medicine rates right up there and that’s for obvious reasons. What we do is in a very escalated setting, it’s obviously resource constrained, a lot of emotion flying. What we do is hard. I advise my colleagues and trainees I work with to assume that burnout will happen. So proactively plan for it rather than assuming that it’s a failure. So just in the way that if you live in a bushfire prone area, you need to have a plan for what you will do, like how you will get your stuff out, what you will do, where you will go have a burnout plan. For me that involved knowing who I would talk to. So, identifying in advance a couple of key friends and colleagues who I felt I was safe to talk to about how I was travelling psychologically, having a plan to have a break.

(27:48):

I’ve experienced two pretty significant periods of burnout in my career and in both cases I needed an amount of time off. I felt the support of my GP to seek medical leave, know in advance if that’s something you can do. I also really feel that planning to have periods of doing other things is really important in your career. So don’t just assume that you can clinically see patients in this really, really high stress environment, continuously, actively plan that every few years you might have a few months of doing something else. I love in the Victorian system that they have a planned sabbatical where for three to six months they can take on a research project or do a course. We don’t have that where I work, but I try to do it for myself. So, make sure I have other strings to my bow. So other things where I can seek satisfaction or engagement because clinical work is really, really hard. I love clinical work, it energises me, but I’ve found that having other things about it is important. And another really nerdy thing, my clinical environment can feel really out of control. I personally have felt great satisfaction in getting involved with the college, with government committees and been actively involved in health system reform to try and improve the circumstances in which me and my colleagues work and to overall to improve the way that patients experience the healthcare system.

Professor Mark Creamer (28:59):

No, this idea that you actually have some agency, some control over your own destiny sort of thing. I agree entirely. I think it’s a very good thing and sort of comes back to the control issue.

Dr Clare Skinner (29:08):

Oh, look at the Whitehall study. We found that we know for British Civil Servants that the more sense of agency and control you feel over your work environment, the better your physical and mental.

Professor Mark Creamer (29:16):

Health. Absolutely. Absolutely. And I do love your idea about actually having a plan long before the wheels fall off, long before anything else happens. You’re sitting down, you’re making a plan if this should happen. I want to talk if we’ve got time quickly about training in a minute but let me go to you Jacqui. What would be your key factors for looking after ourselves or perhaps looking after our colleagues?

Dr Jacqueline Huber (29:35):

I couldn’t agree more with Clare. Something I would add is to recognise, feel entitled to whatever emotions you’ve got and figure out a way that you can personally act on those emotions in a pro-social way. For example, I feel a lot of agitating emotion in my day-to-day work. I take on a lot of what my patients are feeling and I, I feel agitated, I feel a little bit aggressive myself. And my strategy is I do a little bit of martial arts, I hit things, it’s pro-social, I don’t hit people <laugh>, I hit punching bags for example. And I would, I would encourage people to find whatever works for them. My way of having control over my destiny and having a sort of a distal goal, a pathway to meaning and purpose in my life on top of the clinical work is research. So, I’m doing a PhD into emergency psychiatry strategies or treatments, and I think without that I wouldn’t feel like I had a really clear, purposeful direction. And that I think helps me with the potential for burnout because I know where I’m going, and I have a plan for it.

Professor Mark Creamer (30:43):

Yeah, absolutely. And it kind of touches on Clare’s comment about making sure that you’re taking breaks, it is kind of a bit of a work life balance, or a different work balance kind of thing is so important.

Dr Clare Skinner (30:53):

There’s another couple of things there. One is financial sustainability. So, a lot of doctors live within the very edge of their means. I choose not to do that. I choose to live quite frugally so that I know that if I need a break I can financially do it. And I love Jacqui’s comment about martial arts. So, I’m a fairly keen amateur musician and I draw, and I write stories and I actually use all of those things to process my emotions. So, you can basically tell what sort of day I’ve had by what I’m choosing to play on the piano that night.

Mark Creamer (31:23):

<laugh> so the family know exactly when to stay away from you. I’m sure <laugh>,

Dr Clare Skinner (31:27):

I agree with Jacqui. It’s all about, it’s about emotional intelligence. So, identifying your emotions, not reacting to it live, but parking it and using it constructively somewhere else in your life. But also, occasionally I’ve actually often feel quite angry in my work. I hope that the trainees and colleagues I work with don’t notice that I’ll park it, but I might occasionally channel it constructively when I’m not feeling it live into the way I might respond at a meeting or something. Or you know, how a policy might look.

Dr Jacqueline Huber (31:51):

Otherwise known as sublimation.

Professor Mark Creamer (31:53):

<laugh>, yes. But as you say, having something that you can really focus your energies on that’s got nothing to do with work, I think is a great thing. And we, not everybody wants to hit something Jacqui, but if you do, that’s fine. I, I’m certainly I’m certainly a big fan of the basics, you know, practising what we preach in terms of things like regular aerobic exercise and getting enough sleep and eating sensibly and social contact lots of being with other people and that that kind of stuff being very important. And I suppose, you know, also we might usefully learn some strategies, some meditative or mindfulness strategies or you know, relaxation stuff, some good cognitive restructuring kind of stuff as well I think is helpful.

Dr Clare Skinner (32:32):

I think there’s a, there’s another little piece about boundaries here, which is as clinicians we can confuse our therapeutic expertise with the way we manage ourselves or the way we manage non-clinical relationships in our lives. So, I often see doctors making this mistake of assuming because we know how to run a patient doctor relationship, that we know how to run an intimate relationship or a professional or business relationship or even look after ourselves with those skills. Whereas in fact that requires a very different skill set and I think we need to know how to ask for help when we need it.

Professor Mark Creamer (33:01):

Absolutely. Absolutely. Which kind of makes me think about how we are training people and I wonder whether in your psychiatry training or your emergency medicine training or whatever you had anything more much about looking after yourself in this kind of way. I know I trained back in the dark ages, but we certainly didn’t have anything along those lines. Is there anything now, should there?

Dr Jacqueline Huber (33:21):

Be, I don’t remember having had any training in this area, although the college might disagree since your apologies if I’m, I’ve gone back wrong <laugh>, but more recently, yes, there is more, and I think workplaces since COVID have also taken on that role certainly at St. Vincent’s. And I know that AHPRA has a very specific programme as well. Clare, do you know of any?

Dr Clare Skinner (33:41):

Yeah, look, I do remember being taught about wellbeing and boundaries as a medical student and as a trainee, but it was much more through an apprenticeship role modelling sort of thing rather than a deliberate formal curriculum. I think workforce wellbeing is no longer optional. We’re in a buyer’s market, you know, we’ve got extreme workforce shortages, we’ve got a very burnt-out workforce. This is not optional. This is actually core business for any health system employer and it needs to go beyond the superficial.

(34:07):

So, for me, wellbeing is structural. We are very good at talking about behaviours. I worry that that wipes away things like racism and misogyny, which are desperately bad for people’s psychological wellbeing. We know all the things like thank you cards and cupcakes and things like that. But this is actually structural. If we are rostering people too many hours. If we are not providing enough FT to the service to allow people to have leave, if we’re expecting people to be in three places at once to meet patient needs, we’re setting up people for burnout. So, I think we need to look at the structural drivers of poor behaviour and burnout in the system.

Dr Jacqueline Huber (34:39):

I think it’s worth adding that if you do find yourself in a situation where you’re covering three wards or, or three different people’s roles and you take that on, the system will take it. They’ll say thanks and they’ll just take; they’ll keep taking. So, it does come back unfortunately to individual boundaries as well though it is the responsibility of the system.

Professor Mark Creamer (34:59):

Quite, quite. I couldn’t agree more, and I think in many workplaces there is an assumption where we gave them a couple of hours on stress management. That’s all we need to do, you know, and actually that’s useless if the, if the system is set up against it.

Dr Clare Skinner (35:11):

I just wanted to talk about bad behaviour quickly because I think we have seen a lot of focus on medical culture and on bad behaviour in the system in the last few years. But I think we need to be more strategic and purposeful about the way we deal with that. So, I’m very concerned that we don’t just have conversations about professionalism that don’t recognise that people are coming from different places on the power hierarchy. There’s different degrees of privilege and particularly a lot of our notions about what’s professional might be very culturally based. So, I think we need to do that in a better way. The vast majority of bad behaviour in health I think is actually a bad habit. People are role modelled bad behaviour, people learn bad behaviour, they watch bad behaviour getting recognised and rewarded in the system. And we actually need to be very, very clever at purposeful in the way we start to address this. And that’s gonna require expert help. We don’t necessarily know as doctors how to do this. It’s very different to the way we interact with patients. I think there’s expert help we need to enlist to help us address the poor culture we work in in medicine.

Dr Jacqueline Huber (36:06):

Interesting Clare, yeah.

Professor Mark Creamer (36:07):

Yeah, absolutely. I suppose the message I wanna lead people with though is just going back a few minutes and saying there is actually a lot that we can do. There is a lot we can do to help our colleagues. There’s a lot we can do to help ourselves as well. Fantastic conversation. We could easily go on for another hour without any problem at all. But I’ve got this great big clock in front of me and it’s telling me that we’ve run outta time, so I can only apologise for that. We have covered a lot of ground. I’ve thoroughly enjoyed it. I’m sure that our listeners will have enjoyed it also. So, thanks very much to both of you for your time today, Jacqui and Clare.

Dr Jacqueline Huber (36:35):

It’s been a pleasure. Thanks for having me.

Professor Mark Creamer (36:37):

If you miss them, I encourage everybody to listen to the first two episodes in the series where we looked at managing mental health crises and managing suicidal behaviour. Those episodes, of course, are available from the MHPN website where you can also find information on upcoming podcasts. You can even delve into the MHPN archives for offerings from the last couple of years. If you wanna learn more about Jacqui, Clare or me, or if you wanna access any of the resources we’ve chatted about, go to the landing page of this episode and you’ll also find there a link to a feedback survey. So please fill it in, let us know what you thought about this episode and the series and give us any comments or suggestions about how MHPN can better meet your needs. But now it’s time to say goodbye and its thanks again very much indeed to you, Jacqui. Goodbye from you.

Dr Jacqueline Huber (37:26):

Bye, Mark. Thanks for having me.

Professor Mark Creamer (37:27):

Been a pleasure and thanks very much indeed to you, Clare.

Dr Clare Skinner (37:29):

Thank you so much for this opportunity to discuss an important topic with a colleague from another specialty. When we work together, we can achieve wonderful things.

Professor Mark Creamer (37:36):

Yeah, it was fun, wasn’t it? I enjoyed it. Look, a big thanks also to all our listeners for joining us today and for listening to the podcast. We do hope that you’ve enjoyed it as much as we have. But finally, now, it’s goodbye from me. Thanks to everyone. Bye for now.

Host (37:51):

Visit mhpn.org.au to find out more about our online professional program, including podcasts, webinars, as well as our face-to-face interdisciplinary mental health networks across Australia.