Welcome to another episode of the Thought Broadcast, the trainee-led podcast from Australasian Psychiatry, where we demystify the scholarly project and humanize the research experience. Today is an exciting episode for the podcast team. We started this podcast in the hope that we could increase communication amongst psychiatry trainees across Australia and New Zealand. By sharing stories of trainee research and successful scholarly projects, we are creating a platform that offers a new kind of mentorship that is accessible to registrars in all training regions. Today's guest, Dr. Sonia Chibakapa, contacted the team following our open letter to all trainees of the REN'ZCP. She is our living, breathing, and speaking proof of concept. On our panel, we have Associate Trainee Editor Michael Waiteman. How are you, Michael?

Hi Ollie, good thanks. Yeah, looking forward to another interesting chat about a scholarly project today. Great.

And our Deputy Editor, Andrew Amos. How are you, Andy? Oh, I'm I'm great, Ollie. Thanks for inviting me. And my name is Ollie Robertson, and I'm the trainee editor of Australasian Psychiatry. So, Sonia, welcome to the show. Can you tell the audience sort of a bit about yourself, what you're up to in work and life at the moment?

Yeah, certainly. Thanks so much for having me here. So I'm a stage two trainee currently at the Austin Hospital in Melbourne. I'm doing my consultation liaison psychiatry rotation after coming back from 12 months break in training. I've had an interesting sort of trajectory since I've trained in Melbourne and also in New Zealand, in Auckland, as well as living overseas for the last year and planning to go back overseas to give birth at the end of this year. So I guess it's been an exciting last few years, and I'm happy to share a bit about my scholarly project, which I'm quite passionate about.

Fantastic. Could you tell us? I mean, obviously that there's a lot going on, just um how's it going to work when you do travel back to Europe and have you got a plan for your training ongoing?

Yeah, I mean, um, when I first decided to come back to Melbourne pregnant during COVID to do this three months of CL to get half of that done, um, I think I was met with a little bit of trepidation and uncertainty. Um, but I was quite, I guess I've been persevering and I'm quite determined. So I think just the attitude and the positive frame of mind is a really good starting point. Um, and then there's also like prior recognized learning pathways where I could potentially do some of my training in countries like the UK, Canada, um, South Africa. They all have very similar training to Australia, and I'm open to the idea of going back to New Zealand as well. It's just that um my partner's a doctor in France, and so working here is a little bit difficult for French nationals, um, but somewhat easier in places like New Zealand, and that's why I spent a year there. So um, having already transferred my training to a few different places, I'm aware of like the processes, and I think that's an advantage in moving forward, but I'll have to juggle motherhood and travel and yeah, the pandemic too. Hopefully, that's ending soon. So it's possible.

That's amazing. So um the I I suppose obviously our our kind of uh goal with the podcast, one of them is sort of understanding the scholarly project, but obviously hearing training stories more generally and yours is quite an interesting one. And I I'm I'm imagining that other trainees who are facing dilemmas of having partners living overseas or potentially having to travel would really like to hear that you're kind of figuring out a way or navigating that process. Um, Andy, you're a director of training. Is that something that you've sort of had or encountered throughout your time?

Certainly before COVID it was more common. It's not been quite so common recently. And um I guess it depends where in the world you are and and where you're coming from, where you're going to. Sonia clearly is very ambitious in a number of different domains, so I think she uh may be a little bit more successful than other people who haven't persevered, so it's a it's an interesting story.

Thanks for that. But I have also had a lot of help along the way, so I think that's I should mention the credit to others as well. So I've been pretty lucky about that.

Well, should we have a chat about your scholarly project paper, Sonia? So, Sonia, your paper was published in the Psychiatric Quarterly last year, and its title is Profiling Absconders from Public and Private Inpatient Psychiatric Units, a comparative analysis. Can you tell us a bit about the project, how it got started, and um what was going on for you at the time?

Yeah, with pleasure. Um, so I guess absconding was a topic that was introduced to me when I was an intern. Um, I was quite ambivalent about doing a psychiatric rotation early on in my internship and actually took a real liking to it. The registrar who I was sort of shadowing and helping out, he already had um this topic as something that he was interested in and had all this data that he was hoping to get into a publication at some stage. So he invited me to maybe take part in that, whatever that meant. It never really was set out to be my scholarly project, but I did get the exemption much later down the track. Um, and I really felt like it's an area that is quite neglected in the literature. And the more I learnt about it and um discovered, I guess, the atmosphere on that ward, I realised what an issue it was, and that that ward had a history of a patient who had absconded and completed suicide, um, which was a real, I guess, sort of negative um memory for all the staff that had worked there. So there was a bit of that personal interest as well as a real like um lack of, I guess, robust data. So I wanted to have quite an adequately powered study, and we had the data over over 100 patients there, but then my um internship led me to get into the program for psychiatry and start working in a second to a private clinic where I was able to get more data that I could clean and have sent to the statistician and then um merge into this study. So I actually got two papers out of it, and one of them was the scholarly project, while the other was just another publication in psychiatric quarterly, also that they were interested in publishing on the sort of remaining data we had about predictors for absconding.

Is that ability to use your experience across both the private and public sectors is quite a good one? Like often in training we move around a bit, and sometimes that can be a disadvantage, but in your case that's been quite advantageous for your research.

Definitely, Michael. I think um with absconding, it particularly because it's so different in public and private, you've got locked doors, you've got open wards, um, in private, sorry, and in public it's often locked, and then the the rates were so different too. So I think it gave a really good comparison of how you know a similar sort of even cohort of patients sometimes can present um with very different absconding profiles or or risk.

How did you come up with the variables that you were interested in? Was um that based on the data that was already there, or did you have to sort of go through and think about what could be interesting to look at?

I think we started really broad, and um, this is one of the things that made the study really difficult and took a lot of time because later we had to get rid of things that weren't even relevant. Um, but we decided to get more and then taper down. It can work in that direction, I think, but having a clear idea of what you're after at the beginning can also save you a lot of time. So um we were definitely interested in like diagnoses, homelessness, um, mental health act, and whether or not patients had, you know, um centrelink benefits, that kind of thing, indigenous populations. And I think we even gathered religion as well at the beginning. We were trying to just get all the data we could and then synthesize that. But we were very limited when data was missing, and we also relied on patient files as well as CMI. And as you probably already know, um, anyone who's worked with CMI, it's very hit and miss what clinicians enter in.

Is CMI some sort of Victorian disease that we don't know about in the rest of the uh country?

Yeah, it sounds like it. I mean, um all patients who are put under the Mental Health Act need to be entered into CMI and they receive a statewide UR number, which is a great way for tracking them.

So it's an electronic health record. Yeah, essentially, essentially, um, but only accessible to mental health clinicians.

Do you think that there that there are different motivations for absconding in the public versus the private?

We did. We had discussions around why people wanted to leave public, and a lot of it was around smoking. Um, and I think the no hospital no smoking policy came in to act like you know, it's been there for quite a while, but it's still a huge issue. Um, and I think that it was a bit different in private because there was sort of a more designated area in front of the private hospital where people could have um cigarettes even though it wasn't really allowed. But they were also had breaks, and a lot of the private patients could negotiate those breaks with good behaviour. That sometimes does happen in public too, obviously, but it was just very um much one of the things we thought about in terms of what motivated people. Um, and that was one of the statuses that we looked at a variable as well.

Well, yeah, you make you make the point in the article that mental health status, whether someone's being treated involuntarily, is certainly one of the factors. I find this whole thing really interesting. In Queensland, where I am, there's been a huge debate over not only locked wards, all of our wards here are locked, but the the mandatory um exclusion of cigarette smoking. So people would have to go three or four kilometres from the ward in order to smoke. And clearly in the private system, you've got a group of much more uh capable and people with a large larger um set of resources, much less affected by involuntary treatment orders and so on. So it seems like you've you've actually perhaps not looking for this, but you've you've demonstrated something that is a clear inequity in the health service that uh these different groups, which have such different lives and different different uh power sources, if you like, uh, are differentially affected. I was really interested as well by the fact that this is a risk factor for suicide. That is, people who um abscond generally might then go on to commit suicide. Is that is that something that was discussed in your group or that came out in the papers that you've written?

Yeah, certainly. Um as I mentioned, like that was one of the issues that was highlighted to that particular registrar when you started collecting the data as they had had that experience. And um yeah, I think it's something that's actually not well known and not reported on enough. It is mentioned in the literature and I've cited that, and I think raised awareness around that and what it actually means could actually could help prevent further such episodes by screening that or considering predictors like we did in the other paper. So I think that you raise some really good points and and also about the inequity, too, with um Mental Health Act and voluntary and involuntary status and how that influences things, because um, while one group has more liberties and more freedoms that are already given, the other seems to have to fight for those in so many different ways, whether it's lock doors or um mental health tribunals, and and those things tend to encourage that feeling of um needing to escape. And there's really very little evidence to suggest that lock doors are suitable or helpful in the long in like a bigger picture as well. So something to consider about um as well in the future when designing psychiatric units, I suppose.

Sonia, um, I mean the story of a patient absconding from a unit and completing suicide is obviously a tragic critical incident that would have had really um, I'm sure, far-reaching ramifications within that team. And I'm just wondering what it was like uh sort of taking ownership of that data and having that responsibility to kind of um crunch the numbers and come to some understanding about what you could do differently. And was that a good motivator? Was it sort of pressure? Like how did how did that sit with you and the co-authors on the paper?

That's a great question. Um, for me personally, I came after that time, but I felt like it was a great motivator. It didn't necessarily come with a lot of pressure, it felt like there was a need for a shift or a change. Um, and it felt like a story that could happen to anyone, like those tragic things that we hear happen, but you know, could happen anywhere, anytime. And and thinking about prevention, you know, that's that's the best strategy forward. So for me personally, I felt like it was a great motivator. Um, it's hard to speak for my co-authors, but I believe for them, like for the registrar who particularly took an interest in this and was the second author, I think he probably felt a little bit of pressure from my understanding to need to do something about it, which I I completely understand. And I think um when you have research that's you're passionate about or that has some meaning to you, it's just so much easier to do it.

Yes.

You mentioned that you worked with a statistician and and um got some assistance in uh analysing the data. How did you find them? What how did you sort of um cultivate that relationship?

Um initially we had a biostatistician from the location I was at when I first started the project, and they did the preliminary findings, which were quite um, I guess, brief, and that was really nice, but I always felt like I was asking for a favour and I felt very indebted to this person. I kind of was uncomfortable with um wanting someone's help, if that makes sense, without really including them fully on the paper. And then when I moved to New Zealand and the paper progressed further, and I had all the rest of the data, it grew to a larger amount, and I wasn't even comfortable asking someone from a previous service to help me. So um one of the authors on the paper was a consultant I worked with, and we worked together in aged psychiatry in Auckland. So we've developed a relationship through work in terms of um, you know, seeing patients together, and I was, you know, told him what I was doing because he was also publishing different things and really good at stats, and he offered to help and actually do the bulk of the work, and I was much more comfortable in that situation where I could sit down with him and we could do some of it together, and I could learn how to use um I think it was starter software that we did, or SPSS, or one of those. So in that way, I actually felt like it was much more manageable and I was learning a bit more, and I understood more about chi-square tests and all of this stuff that you kind of need to know a little bit about for the MCQ. So that that worked really well.

I I have I feel I have to jump in here. Shamelessness is always a good characteristic to have when you're doing uh research or probably every other endeavor in life. Um so if statisticians are available, that's literally their job, and generally they're not going to be too worried. They'll either say yes, I can do it, or no, I won't. So I'd be encouraging registrars, always ask. And if if they say yes, you you really don't have to worry about it too much.

Um I'm curious, um, you mentioned, I mean, I know we're sort of oscillating between you know giving our stats work to statisticians and then also um getting involved ourselves, but you did this as an as an intern and then obviously have gone into training and then had to complete the MCQ. Did you find there was any crossover between the skill sets? Did you learn a bit about um statistics, study designs, and things that helped you on your exams?

Yeah, um, I think so. I I guess I started as an intern, but I didn't publish or like get the exemption until I was a registrar. So it this project did take an awful long time, and and probably because I hadn't intended it to go in the direction that it went and it was all a bit haphazard. But working with a statistician, actually sitting down and looking at these um like the parameters we were going to do, the things we were gonna test and understanding why we would apply, you know, um the the different tests we did, like logistic regression over, you know, some other tests, that made me wonder about those things more. And when I was studying for the MCQ, it happened to correlate at the same time, and I was I was very grateful for that because I had that lived experience, and I think I did better on my CAP part, like I did quite well on that than some of my friends, or I was happy with what I had done because I felt that I had that knowledge and I didn't have to think about it as much or study as hard. So if you can do your scholarly project and you're happy to attempt some stats, it's it's great if you're doing AMCQ around that time. But honestly, if I had to do it now, I wouldn't remember a single thing. So probably not useful if you do them very separated unless you've got a great memory, but yeah.

It's just an interesting point because we've talked a lot on the previous episodes about um people's clinical work improving because of research and they gather skills that they wouldn't have otherwise had. But I suppose what we haven't really discussed is how research can inform your exam success in in other areas. Um, so I I think it's sort of a good point to make for trainees who are looking at doing their project.

Oh, I definitely agree, um Arlie. I I reckon doing a project like this, one of the most interesting parts is the literature review that you do, and it's reading and interpreting other people's work and understanding how you go from a hypothesis that you then test to uh a contribution to the knowledge, if you like, that is the basis of the the uh the um statistics part of the MCQ exam. So I suspect going through that process, you just internalized a whole lot of information that made it much easier to do the CAP questions. And I say this, I've written some of the CAP questions and have done mock exams and that sort of thing, and it's an area that terrifies a lot of registrars because they just don't understand it. So having gone through that process I think is is really, really helpful. And you did it very early, which means that you've had a lot of time to think about those concepts and internalise them.

So, what's been the impact of your projects on you? Like, has it led to discussions with any of the workplaces that you um that were involved in the project about how to sort of approach absconding and changes in board practice and that kind of thing?

Yeah, a little bit. Um I was invited to give a talk about it in the private clinic at one of our like um academic forums, which happened every week. Um, so I gave a talk there, and I also presented it in a rapid-fire presentation at Congress in Auckland, I believe. So um I wanted to spread the word and I had managed to do that on a few different platforms, and I think it invited um you know similar questions to what I've been asked here, as well as just interest from everyone who I've crossed paths with, and a few people asked me for the slides and wanted to know more for their own services and ideas about how they could maybe pick up on absconding earlier or prevent it and um recognize it as a real risk factory issue.

What would be the highlight of the research for you, Sonia? What's the most important thing that you got out of it?

Um, as much as I kind of complain about some of the tedious work I did, I actually kind of liked going into the hospital and spending time with my fellow co-authors doing some of that, I guess, boring work and the camaraderie that I developed there. I guess when I started it, I was an intern thinking, I think I want to go and apply for this psych training programme. And that was such an exciting time for me. And then actually managing to do that and thinking of this research as potentially a foot in the door with this area that I was just discovering kind of moulded my journey with psychiatry. So I would say that um sometimes that the hard work can be actually the most rewarding, and it often is getting the publication at the end, sure that's great, but you don't feel that as much as you do when you've invested all that time, and and doing that with um other you know psychiatrists that are my future colleagues now at the time was very exciting for a young intern who had all these aspirations and and made them a reality. So for me, it's part of like the success of getting to be a psychiatrist one day and getting to know the people who I'll be working with and sharing that with them because you know it wasn't always fun doing CMI, but when you've got other people to talk to when you're doing it and coming on a weekend and cleaning data and you're not doing it alone, it's it's much easier and learning from them and and seeing how you know your career will progress in the future. That's great.

Well, thanks so much for coming on the Thought Broadcast. We're very grateful to have your company and to hear your thoughts.

Thanks for having me, guys. It's been a real pleasure.

Um and thanks everyone else in the team. Um, Michael and Andy, as usual, thanks so much. Thank you. Thanks, Ollie. No worries at all. Uh, and as usual, we'd like to thank David Beal, also to Sidoni Apprentice who made our artwork, and Shaddy Dave for the music. Um, and then lastly, we'd like to thank Australasian psychiatry for their ongoing guidance and support.