The Thought Broadcast
The Thought Broadcast primarily aims to demystify the Scholarly Project and humanise research by sharing the trainee experience. We will focus on some of the stories behind successful projects, including how the authors came up with ideas and transformed these into published research. Additionally, to complement the podcast series and better support trainees, we will hear from consultant psychiatrists who are experienced in publishing and research, and in supervising and examining the Scholarly Project.
As The Thought Broadcast develops, we hope to expand the podcast to discuss a wide range of research-related content with other trainees and early career psychiatrists. We hope that The Thought Broadcast can be an interactive experience with trainees from across Australia and New Zealand getting involved, and shaping the podcast in the direction that will benefit them the most.
The Thought Broadcast
The Road not Taken – Conversations with an Intern, Part 2
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In this episode of The Thought Broadcast, Dr Ed Miller speaks with Dr Allen Huang, PGY1 intern at the Central Adelaide Local Health Network in South Australia. This is the second of two episodes tracking Allen’s internship journey, with a focus on how his interest in psychiatry evolves across his intern year.
Music: https://freesound.org/people/ShadyDave/sounds/277375/
Logo: Sidonie Prentice
Disclaimer:
This podcast is provided to you for information purposes only and to provide a broad public understanding of various mental health topics. The podcast may represent the views of the author and not necessarily the views of The Royal Australian and New Zealand College of Psychiatrists ('RANZCP'). The podcast is not to be relied upon as medical advice, or as a substitute for medical advice, does not establish a doctor-patient relationship and should not be a substitute for individual clinical judgement. By accessing The RANZCP's podcasts you also agree to the full terms and conditions of the RANZCP's Website. Expert mental health information and finding a psychiatrist in Australian or New Zealand is available on the RANZCP’s Your Health In Mind Website.
Hello and welcome back to the Thought Broadcast, the trainee focus podcast from Australasian Psychiatry. My name is Ed Miller and I'm a editorial advisor for Australasian Psychiatry. I'm joined once again by Alan Hong, who has recently completed his internship in Adelaide. Congratulations, Alan.
SPEAKER_01Thank you. Thank you very much.
SPEAKER_00So this is actually the second podcast that we're doing with Alan. And last time we we spoke, we we explored Alan's preference for psychiatry and his experiences of wanting to do psychiatry as he was going through his intern year. So now that Alan's finished his intern year as of yesterday, we're having another chat just to see how his experiences and his perspectives on psychiatry has gone throughout the year. And so as part of that, we're going to look at Alan's experiences of the year as a whole, particularly the time you spent in an acute inpatient psych unit, and then look at some of your future plans and ideas. So, Alan, so let's start with your time in the psychiatric unit. So can you just tell us a bit about what your experience there was like?
SPEAKER_01Yeah, so I think last time we spoke, it was right before I started my time at the at the RAM inpatient psych unit. So I did that for around 10 weeks in the middle of the year. It was a very new experience, I think. I think first of all, the team structure of the psych unit is very different from normal, from other normal um medical surgical units, usually in other units normally. At least in South Australia, you know, you have a team of consultants and then a team of registrars, RMOs and interns that all work together. But during my time, it was more of a consultant and one like medical officer, so like an intern or RMO or registrar. There's no like actual team structure, which was yeah, it was different and um it was a lot to learn because you never really work directly with a consultant as an intern. And so that was a bit to learn about to to handle and to learn how to navigate uh that.
SPEAKER_00Well, is that is that what it's like around in other places or yeah, well, potentially it's so it sounds like there's an ideal staffing ratio in that unit, but it sounds like it was short staffed. Is that is that what what was happening?
SPEAKER_01Yeah, like some of the benefits that you get from working directly with a consultant is where you get to learn a lot from the consultants and see how they do things uh directly and how they reason the clinical practice. But when there's not enough consultants, for example, at the RA, where I think still currently they're still looking to fill a position there, you end up with very minimal consultants and a lot of trainee doctors like us working with multiple different consultants. So I think I ended up working with four different consultants during my 10-week rotation there, even though I think the ideal was and the ideal plan was only for a trainee medical officer to work with one or two consultants in total.
SPEAKER_00So yeah. So is that because there were locum consultants? So one would come in, you'd work with them for a bit, then they'd leave, and then another one would come in.
SPEAKER_01Yeah, but I mean, even even if like we I think they wanted a locum consultant to come in, but it just wasn't field, I think. Um yeah, I think there's just a very severe shortage of locum psychiatrists as well, um, which made it very difficult.
SPEAKER_00Yeah. So how so how did that compare with other rotations that you did in your intern year? Because that's a that's a really interesting question to me. What was that like for you where you may have had in other rotations one consistent supervisor compared to what you had in psychiatry?
SPEAKER_01It felt very chaotic, if I was to be honest. Um, I think because even though you have RMOs and registrars around, they don't know your patients because you're only working with one consultant. And so you can't really ask your RMOs or registrars colleagues for specific help with this specific patient. You either have to ask them for general advice or find out how to do things yourself or ask your consultant directly. And normally, you know, as an intern, you don't normally ask consultants directly about for their advice on other specialty units. Um, and so yeah, I think I think it was a big learning curve, and I think, especially for interns, you know, we're supposed to be supervised for a lot of things that we do, but because consultants don't usually work full-time in the hospital, sometimes we're just there by ourselves. And for someone, you know, luckily I've I have an interest in psychiatry and I have a previous psychiatry experience, and that was okay for me. But um, for other intern colleagues who probably didn't have any or much psychiatry or psychiatric interest, I would imagine it would be a lot more difficult for them to, you know, work out and know what to do and have any guidance or supervision. So I think it was also a bit, I would say, not dangerous, but a bit unsupervised.
SPEAKER_00Yeah, it sounds like you you felt at times certainly a bit out of your depth and like you were missing that, I suppose, that middle barrier, the middle layer between you and the consultant, that being, you know, registrars and other, you know, junior medical staff that you would have had in other specialties.
SPEAKER_01Yeah, and I think I think it also puts a lot of pressure on the consultants because obviously they're working with a very junior doctor, myself, you know, and so they would have a lot of stress and pressure, you know, knowing that this is an inform who probably has never had any proper clinical psychiatric experience and showing them all the different things that is that they have to do and teaching them all along. And also because it's an inpatient acute psychiatric unit, you're also dealing with very behaviorally challenging patients. So, you know, we have a intensive care unit for which a 10 bed closed ward, and you know, those patients I'll be managing on some days by myself because it's no consultant's subdivision, and I guess it's definitely uh it was definitely difficult there.
SPEAKER_00Yeah. So being put in that situation, yeah. How do you how do you find you you you dealt with that? And what kind of things did you learn, I I suppose?
SPEAKER_01I think I well, I mean, in those situations, you have to learn how to adapt and work out how to provide the best care for the patients whilst also, you know, learning at the same time. So I I was lucky enough to have great RMOs and registrars around who who's who had been through this before as well, and they were able to help and send me resources and guide me generally as well. Also having you know very good allied health staff like pharmacists and OTs and social workers who can also help you know guide you on what you know what to do in a certain situation is also super helpful as well. So I think overall it wasn't you know it wasn't terrible, it was actually very encouraging seeing patient care is not just done by doctors, but seeing actually because we work with allied health staff in the same office, we get to see what they do and all the things that they can help us and input with, which is actually quite a lot in psychiatry. So I think what it taught me was learning how to work and work with the limited resources that you kind of have, but I I guess also it also makes you a bit discouraged seeing this is a mental health ward where it's severely under-resourced, not enough, there's not enough supervision for junior doctors, and these patients are extremely unwell, and having junior doctors who have minimal supervision by their consultant psychiatrists ultimately that may impact patient care. And I guess another thing that which was quite surprising, and um things it's something that I didn't really expect to see whilst on the cycle or in the hospital was lots of illegal substance use. I think I don't know what it's like in New Zealand, but in South Australia at least, uh methamphetamine is the big substance that's used. It's very easily obtained and apparently very cheap as well to obtain.
SPEAKER_00Yeah. It's the same in New Zealand.
SPEAKER_01Yeah, yeah. And um these there are patients on these psych wards who are using these substances whilst on the psych ward, because these patients are allowed to get leave of absence from the ward to go out and you know, smoke or see their fan family or friends. That's what they're supposed to use the leave of absence for, but somehow it seems like you know, drug dealers have managed to catch on that this is happening, and so they are targeting these vulnerable patients outside that hospital, giving them you know these substances. And you know, these patients may not be able to pay for it, but because you know they give it for free, they take it back onto the psych ward, and the patients come back from the leave of absence with you know a low-grade fever and tachycardia, and you're trying to work out what's causing them to you know to have these viral science derangements, uh, what's causing them to have their mental state deteriorating, and then you realize that they used methamphenamines whilst on their leave. And I guess it's it was just frustrating and also confusing as to how the hospital system has and at least at the Royal Adelaide Hospital, and I'm sure it happens in the other hospitals as well, how they haven't caught on and how to stop this from happening.
SPEAKER_00Yep. So it sounds so it sounds like you've had an experience where you you've seen how people can make choices even whilst they're under care or in hospital that that may not be the best, and how do you balance you know someone's right to make choices with the need to you know keep them safe or keep your workplace safe, and to also give you know proper care and how difficult sometimes balancing, yeah balancing those factors can be. Yeah. I'm just wondering, so that that's that's a really good example. And did you learn, I'm sure you did, anything else about you know clinical psychiatry? So, you know, new presentations, you know, diagnoses, things that you've not seen before, and what was your experience of sort of discovering psychiatry in that sense?
SPEAKER_01I mean, I would love to say yes, but I guess unfortunately, majority of inpatient psychiatry broadly categorized into two main diagnoses, schizophrenia and bipolar disorder. Most of the other conditions I actually saw a lot more on my ED rotation where that would present to the ED and they would get discharged straight from the ED. So I guess yes and no. Um, because I mean I I did get a lot of um learning and um experience managing acutely psychotic patients, but you don't really get much exposure to patients who, let's say, have an acute suicidal ideation because those patients will be managed in a short stay ward, and they would get normally get discharged after a couple days from the hospital while these acutely psychotic patients would be in hospital for minimum two to three weeks, sometimes even months, six months, I think was one of one of the patients that I saw. Yeah, and I think that's also different as well, and especially in a you know in a um acute hospital where you know on a medical surgical ward, you will see patients they wouldn't normally stay for six months or longer, but some of these patients are staying in hospital for six months or longer. There's multiple factors that would contribute to that, especially the lack of um mental health beds and rehab beds and step-down facilities.
SPEAKER_00Yeah. And so and so what was that like for you? It sounds like maybe you're hoping for a bit more diversity in presentations and sort of maybe seeing the same thing over and over again or having to deal with these patients that are kind of stuck there for a long time for various reasons. What was that like for you?
SPEAKER_01I guess, I guess I mean, change my perspective of it. I mean, I was coming in with a very naive, um, you know, fresh faced uh look into it, but it also kind of makes sense in a way as to actually it's actually quite good that you know a lot of these, uh a lot of um mental health disorders can be managed in the community. A lot of it is good for the patients to be managed in the community rather than be admitted in a hospital for a very long time. Yes, I guess, I guess that's you know, it's not really boring because each patient is is different in in of itself and each patient there's a lot of things that's happening with them, and so working out what differentiates one patient with schizophrenia to another is also was also a um a good you know learning opportunity as well.
SPEAKER_00What were some of your other experiences um during that run?
SPEAKER_01I guess obviously part of the inpatient psychic experience is also once patients get discharged, what their plan is when they get discharged back home into the um community. So I guess that would be referral processes for that. Now, I'm not sure what it's like in other states, but currently in South Australia, our psychiatric referral system and the community mental health side of things is done on a separate program. And the program, I think it was designed in the 1990s. I think it was it looks like it was designed in the 1990s, a very old program, very clunky, not really efficient or streamlined. And you so you're whilst you're on the inpatient psych, you know, you are balancing two different programs, two different referral systems. And unfortunately, you know, some referrals do get lost in that process. And especially when you know we're trying to focus our a lot of our care in a community and make sure patients are followed up well in the community with good backups and supports there. When you have two separate systems, one of them, you know, our sunrise, so our inpatient hospital program is you know, I think it's being updated, upgraded daily. I think they're trying to trial AI into it as well. But then on the other side, you have the psychiatric referral system and program that is built in the 1990s. You have a very old system with a very new system, and it doesn't really work as well. And that was very um also very frustrating to work with. Obviously, you know, we had to I had to learn how to use all of that together, and it was fine after after a while, but I just feel like that could that's a very easy step, you know, some low-hanging fruit that can be fixed quite easily. Yeah, I'm not too sure. You know, obviously I'm quite new in my role, so I might be quite naive in what I'm saying, but I'm sure some, you know, the chief psychiatrist or whoever's in charge of that, you know, if if if they are able to hear this and see that maybe that could be somewhere we could they could improve in that would definitely improve patient care, but also the experiences by you know mental health workers and doing referrals, if referrals, you know, documentation and all of that in the community as well.
SPEAKER_00Yeah. And uh you mentioned it was frustrating, but um, did you have any other experiences of working in a system which is embedded within other systems, i.e., community teams, referral pathways, information sharing? What's your experience of how that those interacting systems operate?
SPEAKER_01I mean, I think our EMR, um at least in the inpatient hospital system, it is quite well integrated. Like you can see in my health record, which you can see patients' medications from their GPs, you can see shared health summaries from their GPs, which obviously it's not optimized to the best, but it's still something that you can work with. I guess what you realize working in a system where there's multiple different moving parts is it's actually quite difficult to get every everyone um working together and having the same outcome and goal for the patients. And so I guess one of the encouraging things that I saw during my time on the wards were the weekly MDT meetings, which yeah, which really helped clarify what your plans are for a patient, because you get to work, you you get to work with social workers, care coordinators, OTs, pharmacists, and they all you know usually will work by themselves with their own set of outcomes and goals. But once a week when you meet and you discuss these patients, everyone's updated on what the end goal is and what they're doing on their side, which was really helpful.
SPEAKER_00So, and just expand on that for our listener. So, what what worked well in that MDT?
SPEAKER_01What worked well was having each discipline be able to discuss their own issues and what they're working with for the patient. And for us as doctors, because you know, we only do deal we we try to deal with all the other things, but we're not trained as much as, say, for example, in the activities of the daily living side of things for a patient, or you know, where they're going to live or where they're going to get their income from, seeing what the social workers and OTs do on that side of things, to helping the patients recover and have a program that they can work with there was really insightful for me and um yeah, I guess encapsulates the whole bias psychosocial model of care, uh, which we would hear a lot about during our education as doctors, but seeing that actually in action you know on on the psychoards was yeah, quite encouraging.
SPEAKER_00So, yeah, so I guess I guess overall, how did you find it? So coming out of it now, how did it compare to what you expected going into it and sort of where has that left you now?
SPEAKER_01Um I guess it was a mixed experience. I think that would be a good way to describe it. I mean I'm definitely still interested in it, and I guess I'm doing psych RMO year this year in 2026. But on the other hand, also knowing that there are limits to what you know I would want or anyone would want in a public psychiatric system. Yeah, I think I'm still working on what the rest of my career would look like, and you know, I I think it's a good thing that you know uh psychiatry is still an option, but knowing that there are limits to the care that you can provide in the hospital system is definitely you know, it was a definitely dis discouraging and disheartening experience. But I've heard that the community work is also a bit different as well. So I'm looking forward to experiencing that and learning that what that's like. And yeah.
SPEAKER_00Yeah, that's looks, thanks for sharing that because I know I know you had really high ambitions for psychiatry, you know, particularly at the start of your intern year. And it sounds like you've had, as you say, a really mixed experience and probably a not very great experience in that particular unit of psychiatry. So it sounds like you've still got a passion there, but you're keen to explore, I guess, what does psychiatry look like in other contexts, but also keep your options open for for other specialties or other options as well.
SPEAKER_01Yeah, 100%. I think it's definitely good to keep your options open and to know that you know one not so good experience does not define a whole specialty. You know, I'm not saying that my experience at the at the RAW was a bad experience, but it was not what I thought it would be initially. Yeah. Definitely looking forward to to that, yeah, to experiencing more.
SPEAKER_00That's really helpful because that's I think that's exactly why we actually did this podcast. And I think that's why we've done it over the two parts, is because it's really, I think, important to actually capture what it's like for you, but also for you know people in general that are interested in psychiatry and actually what what might turn them away from psychiatry. Because I think if we can actually understand that, that's that's actually really important.
SPEAKER_01Yeah, and it's not like we went into this, you know, hoping that this would happen, but I guess it just happened naturally, I guess.
SPEAKER_00Yeah. What do you think would be the thing that would make you not want to do psychiatry?
SPEAKER_01Yeah, that's a very hard question to answer. Um I guess ultimately you know, the thing that would probably stop me from wanting to do psychiatry would I guess burnout. And it's something that I am aware of, and I definitely felt that a little bit during my psychiatric experience at the RA. But I think burnout would be the thing where you would try to do the most that you can, but nothing's really changing. And if people don't want to change, and people, as in, you know, psychiatrists and people working in the field don't want to change or would look at ways to improve the way that mental health care is delivered, it will make people burnout. And you know, I think we all know that you know, but there's lots of burnout in the psych world, and trainees and I guess even consultants, I would assume, and more so in a system that is just not working, you know, you have burnout in other medical specialties as well as but I feel like in psychiatry is a different kind of burnout. But now again, that's just based off my own experiences and my own exposures. But yeah.
SPEAKER_00Which again is the whole point that we're doing this podcast, because I think your experience is really important. And it sounds like, as you said, you know, there are some aspects of some services which do work well, like your MDT, for example. And then there are many, many aspects of many services, particularly the way that those services relate, which aren't working so well at the moment. So I think it's really important to be honest about that.
SPEAKER_01Yeah, but I guess I mean ultimately I think what kept me going and what made me apply for the psych RMO job this year was the little wins that you get. Yeah, ultimately, you do see patients get better, you do see patients improve, get discharged, and not have a representation in a week or two. And patients thanking you for what you've done, and that ultimately is what I guess keeps me going in the field and encourages me to, yeah, despite all the challenges and the inefficiencies of the system, that ultimate you know, in the end, it's a much needed specialty that people need to go in because there is, you know, mental health issues are on the rise. And we need doctors in this area.
unknownYep.
SPEAKER_00So yeah, I think that perspective on little wins is really if if that's something that you've learned through that experience, I think that's actually a really good thing to learn because things can be really overwhelming. But focusing on the the small things that do work, I think is a is a really good outcome to have. I think possibly just the last question would be what are you hoping that the TAP program gives you or can you know do differently for you?
SPEAKER_01Well, I think so the TAP program, I'm not sure if I don't know if many people know about TAP program, but it's like might be worth just yeah, just highlighting it. Yeah, the TAP program, um, I think it's especially it's the only program in Australia where trainee doctors can do one whole year of just psychiatry, like a service registrar role for let's say surgery, for example. That's kind of what the TAP program is. For me, I I'm doing TAP with the Barassa Hills Florida local health network, so that's like a rural health network with an inpatient psych unit in the city for rural patients and headspace, which is not inpatient, more outpatient focused. So for me, I guess the TAP ranger for me this year would look six months in the outpatient space with headspace, and six months in the inpatient space and at glance at the inpatient acute ward. So that would be a good balance for me to gain more exposure. It's a new health network, new system, new referral system as well. Might I say, like the referral system for the rural and remote mental health teams in the community is a whole separate system to the other two systems that we've been using again. So that's that will be interesting to see how that works. But one good thing, and what what one of the good things about TAP is you get protected supervision time with consultants. That's something that I didn't get as an intern. Luckily, one of my supervisors at the RA did find some time to do that. Um I think because I I was able to talk to her and tell her uh my experiences, and she thought that it would be a great idea to do supervision, which I was very grateful for. And I learned a lot during that time as well. I think that was the best like learning opportunities I could ever have as an intern. So I'm excited that TAP has that actually embedded into their program, and also having weekly teaching times, so that would also expand my knowledge and in in psychiatry as well. So in a nutshell, that's basically the two things that uh is special about the TAP program. And that's also what makes it so competitive from what I've heard. A lot of you know, it was quite competitive this year for the TAP program. Yeah.
SPEAKER_00Yeah. Yeah. Um, all right. Well, I think that might be a good place to finish. So thanks so much for coming on today, Alan, and and sharing with us um, you know, your honest summary and experience of your intern year. And I I actually think you know, the way you've been really honest about it is so important, I think, for people to hear. And knowing that it's not easy, but and and just thinking through you know some of the challenges you've had and some of your reflections and the ways that you've reformulated psychiatry and some of the things you could do differently. I think it's just really helpful to hear all of that. So thanks so much for doing these two podcasts over the year.
SPEAKER_01Thanks for having me as well, and allow me to share my honest experiences.
SPEAKER_00We'd also like to acknowledge Aria Hatakumba and Joe Rose Faito, who give us so much support in producing and editing the show. We're also thankful to Australasian Psychiatry for the opportunity to make these podcasts, as well as Sidoni 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 future episodes, including volunteers interested in being a guest. Please get in touch by email at thethoughtbroadcast.org. That's all for now. My name is Ed Miller. Thanks for listening, and we'll catch you next time.