Fish No Feelings
Wednesday, 30 August 2006
“...it’s OK to eat fish cos they don’t have any feelings”Kurt Cobain 1991
That’s how I felt after getting through training. The committee for exams didn’t care anyway, and now I was going to join the ranks of the oppressors- well, being a consultant was the first step.
I needed to alter my expectations, big-time. I thought I’d get through exams first time- it took me a couple of stabs at the clinicals.
I thought I’d get away without doing the dissertation (seeing as though I was on the Implementation Working Party as the ANZAPT rep, which was bringing in the newer and less onerous examination requirements)- that didn’t happen.
During my training I left one hospital to join another hospital where I hoped I’d complete my training and be able to work as a consultant- that hospital was full of consultoid bods and didn’t need any more. I needed to change hospital to start consultant life. I did my advanced training in Consultation-Liaison, and all up spent maybe two-and-a-half years doing CL- finally finding a part of medicine that I really liked after 10 years of trying. Then to my surprise I discovered that there were bugger-all jobs in CL in Melbourne- it was a very poorly funded part of psychiatry where the disputes over funding basically meant that no one was subsidising it. Jobs were not only few and far between, but if you found one, it was generally only for a couple of sessions here or there. It was general adult for me, and fortunately I now have responsibility for the service’s first episode psychosis programme for young people- it’s given me a niche interest, which maybe makes me some sort of expert.
I was pretty heavily involved with ANZAPT during most of my time as a trainee, so I thought I’d just slot in to some hot-shot part of college political life as a consultant- I’ve found that I need to go slow. It’s like the change from primary school to high school- you go from being the biggest fish in the pond to the smallest, once again.
Now I’ve been a consultant for two-and-a-half years and I’ve learnt a bit- like you need a first consultant job. It may not be what you do in two, five or twenty years, but you gotta start somewhere.
I valued my time in training much more retrospectively. I enjoyed the psychodynamic education my consultants imbued in me in my early training- even though it is sometimes difficult to utilise it every day. However, much as Glen O Gabbard purports, you can use it just about everywhere- from how the multi disciplinary team (dys) function, to how the case managers interact with their patient/ client/ consumer/ mental health resource devourer, to the vagaries of private psychiatry.
What I valued most about my training was and remains the friendships I made with colleagues and other people with whom I worked. That was something significant and I didn’t want to lose that part of my professional life. I did enjoy working with teams, I discovered finally, and so put private practice on the back burner. Public system was where it’s at- I was happy to cop (only) a small pay rise on finishing training- I didn’t realise initially how small. I had it good at my last registrar post. I was on a good pay rate and was doing heaps of overtime and making the most of the helpful salary packaging allowances available.
My pay went up a bit, after tax, but I was certainly thinking I’d be doubling up or something. I’d been making plans to buy cars, buy houses, early retirement and the like. It was only later I discovered that psychiatry is actually the lowest paid speciality in medicine- and that includes general practice!! I’m sure there’s part- time workforce and the like to take into account, but it was sobering. While I was counting pennies, my anaesthetic buddies were buying up big real estate. Even the ones working in PUBLIC practice were on a much better wicket than me. I discovered that the government does not reward talking to patients as much as they do putting them to sleep.
But I sucked it in and resigned myself to the prospect. I found it helpful to spend nearly a year solely in public practice; in order to find my feet as a consultant. It was a steep learning curve and it took some time to gain confidence in the new role. It is the same with everyone I’ve found. You can’t just hit the ground running. You need some space and time for reflection on your practice. A supportive director has been a huge bonus for me to help with legal issues, team dynamic issues, and standards issues. Supervision outside of the service is also a great option.
My peer review group is awesome and is basically an extension of the study group that we formed to tackle and defeat the many exams the college threw at us. My peer review group comprises shrinks with different roles and specialities- child, oldies, private practice, the works. I initially thought I’d need a peer review group specialising in the area of psychiatry in which I was working- wrong. There is much to be said for a heterogeneous bunch of people with different interests and different perspectives. After a couple of years of monthly meetings and hours of discussion we’ve concluded that patients were usually the easy part of medicine anyway- we mostly spend time discussing system issues like managing crap staff or difficult colleagues, or medico legal issues- all over a lovely meal and delicious wine- a crucial part of this civilised gathering!
After nearly a year I began private practice- general- eclectic- adults mainly (although a few types of patients I don’t like treating have snuck through my defences). There are some tough choices to make. How many sessions to do? Do I roll into part of a general practice, part of a formed psychiatric practice, part of a big private hospital (which may have expectations on doing inpatient work- again, not for me) or stand alone? Indemnity insurance. Psychopharm versus psychotherapy? Etc.
My full time public job allowed a day for other things, and so I committed a day for private- as I had committed myself to a large and ugly mortgage. I started with a half day initially for a few months, just to get the feel of it. It reminded me of my time as a GP- it takes at least a year until you feel less scared when seeing new patients. You start realising that you ARE capable and competent to manage most problems, even though it is fair to say that my training didn’t arm me with a complete repertoire of treatment options. Conferences and special training courses are indispensable to learn new skills and approaches pronto. I know people who have put off starting private practice for so long that now they can’t take the first step.
I opted for an established private psych practice, where there was an overflowing waiting list from the practice principals- this meant I inherited some patients and could take on as many new patients as I chose- a blessing of the highest order. The practice was fully administered, and I took this fact for granted initially as I didn’t realise how important that was. They managed my waiting list, they confirmed all the patients the day before the appointments to minimise no-shows, they sent out an intro letter for new patients (read “rules of engagement”) so patients knew they were expected to pay on the day and that if they didn’t attend they’d get slugged a cancellation fee- all news to me. They filled in the gaps in my day, they kept a record of my billings, they did my banking and they typed the letters I dictated. They did everything. The full shebang I could possibly wish for. The gold standard of private psychiatry.
To get set up in private you need a provider number- officially this is where you will be doing private but this takes a few weeks to happen once you ask for the paperwork, fill it in and send it off. You can only do this once you have sent in all your forms to the HIC to be recognised as a specialist for Medicare billing purposes. You need the new provider number in order to get new script pads- this takes another few weeks to happen. You need business cards and importantly a policy of how patients can or can’t contact you after hours. I have a mobile phone that patients can call, but I let them know I’m no emergency service and won’t generally answer straight away. Some people use pagers- I hate them as they remind me of being an intern and not even being able to go to the toilet without being disturbed- but that’s some issues I still need to work through! You can let GP’s and the local hospital know you’re setting up shop, and you’ll probably find you get (overly) inundated with new referrals.
Private is different to public practice in several ways- you get to choose who you want to see- you don’t have to see everyone- you get to say NO, even though that can be hard. You can see a patient for an assessment then decide you don’t want to see them again- you are allowed to (a novelty after years of being a registrar!- you do feel guilty saying no to people, but this fades). You charge commensurate with the work you do- if you do a report after hours for someone, you’ll get reimbursed for it- and often well-reimbursed. You get bugged after hours in private, but that settles down depending on the sort of patients you see and whether they are new to your practice and are just testing the waters.
I started off doing no inpatient work and have still managed to resist. It may well be extra money, but it is significantly extra time and my mortgage doesn’t need me as much as I need my family. I have found private practice to be the most rewarding part of my week. But a whole day of it is a whole lot and I still get tired afterwards. People do full time private (I don’t know how) but I couldn’t. Maybe you need more mental toughness, or like marathon running, it’s about putting in the hours and maybe it becomes easier with time. More private also means less time with colleagues and less time with teams- not appealing to me.
I’m involved with the college again- after some time of ambivalence. It is enjoyable and so far worthwhile. People on the college doing their various roles give up (ridiculously) enormous chunks of unpaid time. I sit on the Victorian branch of the college as a member and have been co-opted into a couple of roles. The Vic branch meetings are often fun, sometimes stimulating and generally another learning curve. There is a lot of important work the college is doing- both internally and in the community. It is interesting to be in the midst of healthy and unhealthy debates. It helps me to form views both on the college and the profession I’ve chosen; and it helps me to review my initial opinion that maybe those fish, do, in fact, have some feelings after all.
I am probably not doing the work I thought I’d be doing five years ago, but I like my work and I like my life.