Hello and welcome back to the Thought Broadcast, the trainee focused podcast from Australasian Psychiatry. My name is Ed Miller, and I'm the trainee editor of Australasian Psychiatry. Joining me today is a new voice on our podcast, Alan Huang, our first intern associate trainee editor for Australasian Psychiatry. Welcome, Alan. So this will be the first of two podcasts that we will record over the course of this year, where we track Alan's journey through internship. This will hopefully give some insight into how Alan is experiencing internship. And we're also going to take a particular interest in Alan's exploration of psychiatry as a career and how this may evolve over the course of the year. And we're also going to be looking at Alan's thoughts about psychiatry and particularly compared to the other specialties that he's going to be doing throughout the year. So, Alan, you're a first-year intern. You've just graduated medical school in 2024. Can you start by just telling us a little bit about yourself?

I'm originally from Sydney. I moved to Adelaide for medical school and I graduated last year in 2024. I'm currently working at Adelaide at the Queen Elizabeth Hospital. I'm currently on the Upper GR surgical rotation. I'm married to my wife Abby and she's a primary school teacher, and so that's that's really helpful coming home and not having to uh discuss about anything that happens in hospital. Yeah, we also enjoy going to church on Sundays. We run together, swim together, and sometimes we cycle together when I get the time nowadays.

Cool. And I think you mentioned it, but just tell us a bit about your intern year at the moment. So, you know, where you're based or maybe where you'll be based throughout the year and how many rotations you've done so far.

Yeah, so uh this year I started off as a reliever. So I actually did everything from ED all the way to rehab, so followed the whole patient through the through their journey in the hospital. Currently I finished relieving now. I'm on the upper GI surgical rotation at the Queen Elizabeth Hospital. And it's very different dynamics to relieving. The hours are long, but patients are also very sick, and the patient list is also very long as well. After Upper GI, I'm moving on to psychiatry at the RA from acute mental health, and just to get some experience just to see what it's like working as a doctor in psychiatry. And then I finish it off with an E rotation at the RA and then a general medicine rotation back at the Queen Elizabeth Hospital. So I think this first intern year is uh is a good base and experience for all specialties around.

Cool. So how have you been finding it so far?

Currently on Upper GI, I think it's been hard work. I've been waking up early, getting to the hospital early, pre-rounds and rounds every day, very high patient loads and very sick patients as well. But I actually enjoy the challenge of surgery, the fast pace of how everything moves, how patients are discharged, and the structured and clarity of surgical pathologies.

Yeah, it's usually going back to my memory of surgery for my interior, it's generally pretty pretty well structured. Like patients come in, everyone in the team has you know your role pretty well. You've always got plenty of discharge summaries to do. So you you actually entered medical school with an interest in surgery, I think. So can you tell us a bit more about that interest?

Yeah, so I I enjoy surgery. I came into medical school thinking that's what I want to do because it's very hands-on, it's very practical. And you also work in a big team with different moving parts, and everyone just knows their place and what their role is in that team. And I also enjoyed the clarity and the structured format of surgery. So knowing what presenting concerns a patient has and what physical exam finding can correlate to what treatment methods to use, and also just the discipline that's required in surgical work, being able to consistently do ward rounds, go through patients, see patients in their most sickest moment, and be able to work under pressure in that time with limited resources as well.

So you came into medical school thinking you were going to be a surgeon or at least having an interest in surgery, but somewhere along the lines, you've actually developed an interest in psychiatry. So I'd be really interested to know a little bit more about that. Where did that come from? And what's the story behind that?

Yeah, so I had a brief discussion uh about this topic uh with my fellow upper GI fellow last weekend on a cover shift that we did together. And um, he was just sharing his own experiences of choosing a career path, and he gave me three tips to think about. So the first one, uh what he said was the pathologies that are involved in in a specific specialty. For example, in upper GI surgery. Unlike other surgical specialties, there are some diagnostic uncertainties in that, in terms of some someone with upper quadrant pain can have different pathologies causing that. And he enjoyed that, and I think that's also something that I enjoy. Second, um, it's the people and the environment that you work in. So is that in the theaters, um, in the outpatient clinics, and also the people that you're involved in. So, is that the ward nurses, the theater nurses, and your colleagues that we're working with together, and also the patient cohort and the patients that you see. The third is the time, the lifestyle involved, how long is training, what's training going to be like, what's the training pathway like as well. And first of all, the pathologies involved psychiatry. There is that diagnostic uncertainty that psychiatrists have to sit with and explore and investigate further. And I think I enjoy being able to do that. Second, I think it's the patients that you see in psychiatry. These patients are patients that you don't normally see in the um in your day-to-day life. They're also very vulnerable in their life as well. And so being able to be in that point in time and be that doctor that heals and treats and helps that patient get through whatever they're going through. I think that's really rewarding. So the surgical training pathway, as many would know, is um is long and lots of hours out of our work as well. Similarly, in psychiatry, it is long, but in terms of the lifestyle, there, it's more lifestyle-friendly specialty think. I think that's very attractive for early career doctors, interns, and students who are thinking of where to go as well.

So, what experiences in psychiatry have you had so far?

I've only had six weeks of psychiatry learning and placements in fourth year in medical school. And in sixth year, we also do four weeks of psychiatry. So in medical school, in fourth year, I did six weeks at the rural and remote placement at Glenside in Adelaide.

That's an inpatient unit, isn't it? So that's where people come from more rural parts of the state to get inpatient psychiatric care.

Yes, yes, that's correct. And so it was a more acute inpatient unit where you see a lot of patients in the more acute phase of their recovery journey. And in sixth year, I did an outpatient service um placement up north in Adelaide in a child adolescent mental health service up north. And that was also very different in terms of the patients that you see and how long you spend with them as well. And also in medical school, I was lucky enough to go to Johns Hopkins for my psychiatry placement for my dean's elective. And I think that really helped shape my interest and want and desire to think about psychiatry as a potential career choice in the future.

And so, in the time that I've known you, yeah, I really get the sense that this experience that you had in Johns Hopkins has had a really profound impact on you. So just tell us a bit about that. So, how did you get into that placement initially?

So, initially, in sixth year in Adelaide at least, we're lucky enough to have a dean's elective. So, that's an elective that we get to choose where we want to go and what we want to do. It's very flexible and is very free. So, that's four weeks in sixth year that we can apply via any hospital or university that we would like to go. And so for me, that just involved me emailing professors, psychiatrists, doctors, anyone that would be interested in taking me along for a placement there. So in fifth year, when I was thinking about all of this, I stumbled upon the perspectives of psychiatry, which is what they use at Johns Hopkins. And so that got me interested in terms of I'd never heard of this framework before. And so I cold emailed uh Dr. Margaret Chisholm, who's the director of that um of the program up at Johns Hopkins. And surprisingly, I got a response back from her saying that she would love to have me there. That's how it got started.

It sounds like so you'd already started thinking about psychiatry as a career before that, and this was kind of like the fuse that lit the fire, possibly for you.

Yeah, I think before I wanted Johns Hopkins, I was considering psychiatry, but it wasn't really a convincing career option, but I didn't totally rule it out from the options I had. Having this opportunity up there really helped further that desire to want to pursue that.

And so you've you've touched on the perspectives of psychiatry, which is the framework that's that has been developed at Johns Hopkins. Can you tell us a bit more about that framework?

Yeah, so the process of psychiatry at Johns Hopkins is very different from my medical school educational psychiatry. And when I went there, I think the first few words that I uttered there to Dr. Chisholm was, that just makes so much sense. And what made sense was the structure and the framework that they use to teach students and to also think about and formulate patients. For myself, who enjoys structure and clarity, I think that really resonated with my previous desire of surgery in the structure and clarity side. The perspectives really helped further that in that now I know that psychiatry can have a structure and it can be done well in that there can be precise and good psychiatric care through this structure.

So just going into that a bit more, so what are some of the parallels between, I guess, this framework of psychiatry and and the other specialties, like surgery, for example? Because I because I I agree, I think often psychiatry is seen as very, very different to surgery. But I think there are actually more things in common between those two specialties than might meet the eye. And maybe this framework will help to shed some light on that.

Yeah, I know. Um I think it sounds very counterintuitive at first, I think. People normally put surgery and psychiatry on the opposite sides of the spectrum. But there's actually a lot that are very similar. For example, in surgery, you intervene with intent, you investigate the cause of the issue, you plan and prepare what is required, such as an operation, and then you execute that plan. Surgeons don't go in blind. Um, and similarly in psychiatry, there's a very similar approach to that. For example, in an eight to 12 week intensive psychodynamic therapy, it's not casual, it's structured. You're identifying the cause of someone's distress, mapping the psychological terrain, working towards a purposeful end result or transformation of how they think. And to me, I think that's very similar to an operation. It's just not happening with scalpels or with diathermies in the operating theater. It's happening with exposure, negotiation, and persuasion techniques with a person face to face in front of you.

So you're obviously someone who enjoys being challenged, which is which is a good thing. In what ways do you think psychiatry and surgery challenge you differently?

So I think for surgery, surgery challenges me physically and technically. There's the long hours, the high stakes that's required, and the rapid decisions that um have to follow after a presentation. There's also a disciplined rush to it. But psychiatry challenges me psychologically, managing complex lives, being okay with uncertainty, and working in a team with very limited resources. Um there's also the challenge of having to be aware of societal issues and trends that may cause more vulnerable patients to be more susceptible to pathological ideas and behaviors. I think with a surgical complication, you can usually find at the moment it happened. However, with a psychiatric complication, it's not as clear-cut initially. You need to consider patients' relationships, insight, adherence to medications, substance use, and even broader societal determinants like housing and finances as well. I think you need to also integrate knowledge from the four main domains of psychiatry: neuroscience, psychodynamics, behavioral, and psychoanalysis. And I think that level of systematic thinking is very demanding and challenging as well. And at the same time, it requires psychiatrists and trainees to not go on autopilot in psychiatry. It forces us to be clinically sharp and emotionally attuned to the patient.

So you mentioned having a chat with your fellow a couple of weeks ago. And I'm just wondering, you know, when you mentioned that you've got an interest in psychiatry to other specialties, what's that been like for you? And how have those responses or conversations gone?

Yeah, I think the first thing when my fellow asked me what I wanted to do next year and the year after, when I first heard that question, I was hesitant to say, I'm thinking about doing psychiatry. But I ended up saying that, and the response that I got from him was, you're too good a doctor to be to be a psychiatrist. Now, that's something that I've heard quite commonly from people that find out that I want to do psychiatry. And I think psychiatrists need to be good doctors, and I think they are good doctors, and there is this perception of psychiatrists as not being doctors.

So, what's that like for you to want to do something but to for it to be seen as being inferior to what other people are doing?

Well, I think it's it's disheartening in that other medical and surgical specialties don't see psychiatry as a specialty that's alongside them, but inferior to them. And I think there's multiple factors that play into that. And I don't want to assume based on what other medical and surgical specialties think. But I would say I think psychiatrists have have played a part in this image in terms of changing the language that we use and seeing patients as now consumers and clients instead of patients and reducing the work of a psychiatrist to a point where now in New South Wales the government is even thinking of replacing psychiatrists with social workers, psychologists, mental health nurses. They're not, these aren't doctors, these aren't psychiatrists that are trained in specialist psychiatry. They're trained in social work, in psychology, and yet the government in New South Wales believes that they can be replaced by these other allied health specialists. And I think when a government thinks that, I think that really speaks to what the broader population and what the broader medical community thinks about psychiatry.

Yeah, that's a really good point you raise. I think that's why the advocacy that the the college does at a government level is really important. And also a big topic in psychiatry at the moment is actually what do psychiatrists do? What are our roles and our jobs?

That's the question of what is a psychiatrist and what the psychiatrist do is a question that's really never fully touched upon in my own experience. And in my own everyday interactions, I think lots of people think a psychiatrist is just a prescribing psychologist, which it's understandable as to why the public would see that. But I think psychiatrists are a lot more and can do a lot more in the field.

So you mentioned that your next rotation in your intern year is going to be your psychiatry one. Tell us a little bit more about that rotation and what your expectations are for it. What are your fears and your hopes for that rotation? What do you think it's going to be like and what do you hope to gain from it?

I think first of all, my next rotation, psychiatry, will be a big change from one I'm on now in terms of the patient population and the everyday tasks. But as I said before, surgery and psychiatry, they're very similar in very similar ways. I think what I want to get out of my next rotation is to really apply what I've learnt at Johns Hopkins and my medical school training into my practice with patients in an inpatient acute setting, with very time-limited resources and very limited staff around as well. And seeing what it's like to work in that environment with these patients and with my colleagues around as well.

I wonder what it'll be like for you once you're in an environment where you are around like-minded people and you don't have to feel like you have to constantly justify yourself to other people.

Yeah, I think I'm excited actually for this next rotation. I think it'll be a very good experience to work with other psychiatrists and trainees and learning from them as well as teaching and sharing what I've learned from Johns Hopkins with that framework and to improve the field of psychiatry and to improve the patient outcomes and the treatments that we offer patients as well. So I'm really looking forward to that uh rotation.

So, where do you see yourself going in the next five years or so?

Next year I'm thinking of applying for the TAP program, which is the Adelaide Pre-Vocational Psychiatry Programme, which is unique to South Australia. And it provides RMOs or PGY2 doctors the experience of working solely in psychiatry with two six-month rotations. And then after next year in 2027, I'm hoping to apply for the official training program as part of the college.

What made you choose to do that program rather than applying straight into the training program?

Which you you could do when I when I was an intern, but uh maybe they've changed it since Yeah, um that the college that has actually changed with the introduction of the new AMC framework, with the new introduction of the so-called two-year internship. There's lots of specialties that now require two years of general experience before you're allowed to apply for that training program. And I think the college psychiatrist is one of those colleges that has now introduced that. So, and I think it's lucky for me to be in Adelaide to still have that training, but not formal training in a registrar training program.

I actually did that TAP program in 2016. So it's excellent, I'd really recommend it. Well, that's all we have time for today, so we'll bring the discussion to a close. I'd like to really thank Alan for coming on today and having such a rich and interesting discussion. And I look forward to having a chat to you again towards the end of the year. We would also like to acknowledge Nish Takuma from the college who give us so much support in producing and editing the show. We are also thankful to Australasian psychiatry for the opportunity to make these podcasts, as well as to Doni Prentice for our artwork and Shady Day for our music. We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors. We always love getting feedback or suggestions for further episodes, including volunteers interested in being a guest. Please get in touch by email at thethoughtbroadcast.podcast at ranscp.org. That's all for now. My name is Ed Miller. Thanks for listening, and we'll catch you next time.