Bruce Singh

Interview with Prof Bruce Singh

Saturday, 08 May 2004

This month ANZAPT interviewed Prof. Bruce Singh. He is Cato Professor and Head of the Department of Psychiatry at the University of Melbourne and works in the Victorian Department of Health as ministerial advisor. He is actively involved in psychiatric teaching, research and Consultation Liaison Psychiatry. ANZAPT asked about how he viewed the next 5-10 years of psychiatry. The interview that follows speculates on a period of great change in the public and private system. We find out why Psychiatry of the Aged and Forensic Psychiatry are the sub specialties likely to rise, who is going to move in on our turf, where a psychiatrist's core business is likely to lie, the future of the college system and why registrars need to get involved in their psychiatric future now.

When registrars were polled in the August edition of The Responder the leading reasons for choosingpsychiatry were listed as the following:

We put these findings to Prof Singh and asked him what he felt the near future of psychiatry held?

He stated that the current landscape of not enough doctors to fill psychiatric positions would continue. This gap is presently filled by overseas trained doctors and this is likely to continue. It is feasible that there could be a large injection of funds into the mental health budget blown in on political or health consumer demand wings as recently occurred in New Zealand.

In Australia only 7% of the health budget goes to mental health compared with higher figures eg 11% in the UK. This would some what alleviate the continual short fall of doctors to psychiatric positions required to run the public system. If overseas doctors recruitment is not continued it is conceivable that nurse practitioners or psychologists with prescribing rights might be mandated to service some of the areas to which psychiatrists and psychiatry registrars traditionally attend.

When asked what he feels psychiatry has to offer he replies that the bio-psycho–social model is unique to our discipline and is likely to be our key relevancy and skill. This means that we could be more likely to be involved in the assessment component of a mental health team rather than longer-term psychiatry or psychotherapeutic therapies.

The private sector is also likely to change. There will be a need for the expensive resources of a psychiatrist to be rationalized for long-term therapy with forms of justification for duration of therapy. Furthermore, there is likely to be accountability required that the sickest patients are the ones receiving long-term psychodynamic and psychiatric interventions and if that is not the case, patients are more likely to be required to pay themselves for this service.

Prof Singh feels that Item 319 raised several years ago flagging to cap medicare remuneration for psychotherapy consultations was only the first warning of this approach.

With the new College training program, registrars are choosing their own advanced training stream with a likely follow on to area of sub-specialty.Prof Singh indicated that with the aging of the population areas such as Psychiatry of Old Age was an area likely to expand. He also listed Forensic Psychiatry as another area of growth pointing to places such as California where the largest psychiatric institution was the prison system. He indicated that this trend was likely to follow suit in Australia.Child and Adolescent problems would also be prominent but he was not sure where psychiatric services would place themselves in relation to this from a point of view of defining their place in treatment.Consultation Liaison Psychiatry is expected to increase with hospital beds being occupied with sicker patients and the relationship between this and concurrent mental illness being better understood. The question of who would pay for this increase was not, however, clear.

In general subspecialty areas seemed to be the way of the future with the idea of General Psychiatry not as popular. Certainly in the UK these positions are harder to fill especially in the inner city areas where patients are particularly unwell.

Once again this trend feeds into the problem of service provision in rural and remote areas and “areas of need” which is likely to continue as a pressing issue.

The issue of work life flexibility initiatives and the desire of many psychiatric registrars choosing this specialty as a life style option was discussed. The balance will probably have to be sought by individuals. An overstretched system was unlikely to afford this by itself unless some service provision alternatives were found as already discussed.

Psychiatry registrars describe significant levels of stress experienced as a result of training and the training environment as described in AMWAC and University of NSW study conducted by Gary Walters. As workforce shortages continue this is not likely to abate. Prof Singh indicated that if this were the case then it would be likely to impact on recruitment and retention in psychiatry further exacerbating the problem. He indicated that this trend was not unique to psychiatry with other specialties such as Obstetrics and Gynaecology and Surgery being affected.

ANZAPT asked about the future of the collegial system and the RANZCP in particular in its current capacity of professional self-regulating body. Prof Singh talked of an inherent conflict in Colleges in general, making it difficult to discharge their various duties. This came down to, on the one hand, providing a collegial atmosphere amongst their professional group and on the other hand being required to regulate the profession and meet work force demands. He commented that the College recently giving up its role of deregistering psychiatrists to the medical practitioner’s board, on the basis of having no particular statutory authority to handle this, an example of the difficult situation colleges found them selves in particularly in relation to achieving work force requirement in rural and remote areas and designated “areas of need”.

At the end of the day they could end up being the body that decide how many people they train each year to be psychiatrists.

ANZAPT raised the sceptre of work force supply pressures hanging over all colleges with a possible out come being that In the future this could fuel the out sourcing of training to other institutions such as universities or a “public health system” style university with contracted training to meet service demand in specific fields and areas. Prof Sing agreed that this was certainly conceivable.

By the end of the interview it was clear that there was no guarantee of the reasons driving registrarscareer choice of psychiatry being met,with the professional goal posts perpetually changing.In view of the large investment trainee psychiatrists and indeed all doctors make in becoming aspecialist this risks leading to professional dissatisfaction and disappointment. Pressures oftraining and hours worked can lead to a certain exam and survival myopia making participation in the direction of our chosen path limited and passive. When asked about the best way to protect our 'investment' Prof Singh said:

Get organized, form opinion and be involved in making representations to the relevant government bodies either directly or through the College because a lot will change in the near future.”

Deeta Kimber ANZAPT