The Final Friggy
The Final Friggy Print E-mail
Tuesday, 23 December 2008
By Dr Frigmund Pseud
Here is a collection of ramblings based loosely on those I submitted to my training coordinator by way of a Final Qualitative Report prior to fellowship. As Reports go, its Quality is debatable, but it is certainly Final, and that feels pretty good. Which reminds me (you’ll see why) – I’ll stick some pearls from my training down the back for anyone who’s still awake…
Advanced Training - It’s All About The Jacket
Over the past 2 years I have passed my clinical exams, found a subspecialty, and now feel as ready as I’ll ever feel to start out as a consultant psychiatrist. Based on these things, my advanced training has been a success.More importantly, I can now wear my moleskin jacket with pride. At the end of my basic training, the clinicals loomed ahead, and I felt unsure of what to do with my clear interest in developmental psychology and personality theory, with so few opportunities to pursue such things in the public system. I didn’t know what I was going to do with either of these anxieties. I bought a moleskin jacket at this time, to try and feel like a consultant, as I’d read and heard that to pass the exams you needed to walk the talk, and believe you were the real deal. My struggle to fill the jacket over the following 24 months was I think what advanced training was about. What is a psychiatrist? Someone who did the training, passed the exams, and turns up for work? Well, yes. But I felt I was going to need to present something more than that.
This is not to understate the massive effect of the clinical exam process in my development. Before the clinicals, I thought of everyone who had passed as superheroes. Paradoxically, I also would have voted to chuck the clinical exam process if ANZAPT had held a vote on the matter, as I was sure that I was a good registrar who didn’t need some phoney acting exercise - that cost thousands of dollars and added many grey hairs to your head - to prove it. Now, I am glad ANZAPT didn’t have a vote on it, and if they had, I would be glad that no-one at the College had paid too much attention. This from a vocal supporter of ANZAPT, and a past detractor of the college assessment process – I think the exams are a good thing.
Before the clinicals, I was a good reg who brought a congenial, meandering style to interviews and clinical discussions. This was clearly appropriate to some psychiatric settings, but not all, and certainly not the crucible of an OCI or OSCE. I needed to change how I worked, and the exam preparation made me do it. I became, out of necessity, more focused in my interviewing, yet also better able to stand back from a busy exchange. I learned to take notes as I worked, a feat of multi-tasking I previously thought impossible, and now find essential. This was really hard work, but any change is. And change I did – I recall a colleague marvelling at my apparently cool exterior on the day of a dress rehearsal OCI, which contrasted with my churning gut and absolute conviction that I looked worse than my patient could possibly look. This was a crucial insight. I am not transparent. I can look the part, and do this thing. The examiners agreed. I came away knowing more psychiatry than ever, relieved I did not at that stage need to know any more about hotels in Auckland, and possessed of quite a few grey hairs, which my wife thought matched my jacket well.
The aura of the successful exam candidate did not last longer than a few weeks, a period of rest granted me by my punitive superego in an idle moment for which it has yet to forgive itself. After that, I noticed that post-exams trainees no longer seemed superhuman to me. The goalposts had moved again. And I still had many days when the jacket fell deflated off my hunched shoulders, so I put it away, worried someone might say ‘he thinks he’s a consultant already – getting ahead of himself!’ (although I’m sure only said superego would have been so unkind. It works hard)
Even now I have days when the jacket doesn’t fit. But I don’t let it bother me as much. I just roll my sleeves up and march, hands in pockets, along the hospital corridors like I did as an intern, only with some grey hairs, and a belly. I put my head down over my files, ask careful questions of my patients, and write until my hand is sore. Then I go home and sleep deeply, and the next day I wear the jacket. People around here having been calling me ‘psychiatrist’ for much of this year. Where it matters technically, I correct them, but mostly I let it go. They’re not too far off the mark.
So, what about the RANZCP’s Generalist Advanced Training Programme did the trick? Was it the 9 learning goals? The ethical activities? The 25 hours’ minimum CME? Well, taken together, a bit, perhaps. These are structures the College puts in place to apply fairly to all advanced trainees, for consistency, and to make some claim to activity in training people who are close to becoming consultants. They may be important to some trainees, serving as a guide, or as a containing set of rules to follow, but I don’t think they’ve made me a psychiatrist. There is some overlap between the tasks I’ve done to tick boxes for the logbook and those I’ve pursued to get better at my job; naturally I feel that the latter have done more to help me grow towards fellowship, although most of that growing has had little to do with tasks, whether the College made me do them, or I did. Most of what mattered happened at work, under supervision.
I’ve thought for some time now (ever since CAMHS, actually), that training is a developmental process like any other. I have seen myself move from a paranoid-schizoid position with regard to supervisors - wherein I idealised then devalued them, especially in the infantilising and tumultuous first year - to the unfairly-named depressive position in later years. Growing comfortable with my supervisors having ‘good’ and ‘bad’ elements with regard to my needs of them, I could venture further from the secure base they formed for me. I internalised elements of each ‘good enough’ supervisor; as I got to know them I would come to predict their responses to my phone calls for most clinical questions, which often meant I didn’t need to call them. Those elements are still with me, such that now for a complex clinical dilemma I can call upon a full bench of old bosses that sit within (alongside Chief Justice P. Superego), of whom I can ask ‘what would you do?’
Ultimately, it’s what I would do that matters. My jacket is a patchwork of theirs, although with time the seams are fading. This is what advanced training was for me: growth.
OK, now for something a little less formal:Friggy’s pearls from medical training 1995-2008
‘I feal preeady gud!’ This from a patient in my intern year who had Everything. She was a walking Harrison’s. She was 50 and looked 70. We would see her for the umpteenth time in outies or on the ward, and this is what she would say. It’s not just her crazy accent I remember – I channel her resilience, reciting her mantra, accent and all, in times of stress. Ask my wife.
Med students know something doctors don’t. As we train, we trade something valuable for our developing expertise, and that is a normal perspective. At the start of my tutes these days, I begin by asking the students how they’ve found psych so far. If we’ve seen a patient, I’ll ask for their responses first. Often that’s done so the teacher has something to correct, which is fine. I do it because I can’t remember how I would have reacted to psychiatry or a patient in psychiatric treatment, as a lay person. Sure, I have a memory for life before medicine, but I was 17 then, and I’ve been seeing and doing stuff most people don’t see or do for my whole adult life. The students have something valuable – their inexpertise.
It’s OK to accept gifts sometimes. We’d had it drummed into us as junior registrars that gifts were a no-no. I will never forget the complete hash I made of a family’s gift to me of chocolates at the end of a rotation wherein I’d worked closely with them. I stammered and pfaffed about, eventually accepting them on behalf of the team. Years later, I see that in trying to avoid a theoretical risk, I’d put at risk so much of the good work I’d done building rapport with that family. I really hope it’s not their abiding memory of my time with them! Nowadays I accept gifts in most circumstances. Sure, there are times when it’s not appropriate, and we always need to take care in considering this when offered a gift. But I think giving a gift to someone who has tried to help you is for the most part a tender thing indeed, and I allow myself to be moved, just like any normal person would.
Being a good doctor isn’t something you do, it’s something you…be. Are. My professionalism is something I’ve come to cherish, despite years of kicking against the medical orthodoxy as a young pup. Actually, stopping after 3 years practising medicine to do something else for a year was what made me realise I wanted to be a doctor, not just practise medicine to pay the bills. Coming back to it, I could see what it had made of me, and what I could make of it. Identifying as a doctor has changed how I work. There are many decisions in my job where there’s what I could get away with – citing limitations of the system or hierarchy, for example - and what I know, in my heart of hearts, I must do for a better outcome. When I go with the latter I like myself a lot more. This is not to say I am a workaholic above-and-beyond undies-over-trousers sort who sleeps under his desk. Rather, I do a good enough job at work to sleep well. At home.
Having a kid is indescribable. I have learned more from my toddler than any professor, textbook or exam has ever taught me. I dine on humble pie daily, and I’ve never felt more alive.
I could go on, and on, but that’s enough of me. Good luck with you.
Thanks for reading over the past 5 years.
-Friggy