SPEAKER_02 0:07

Welcome to another episode of the Thought Broadcast, the podcast from Australasian Psychiatry made by trainees for trainees. We have a smaller panel today. We have the Deputy Editor of Australasian Psychiatry, Andrew Amos. How are you, Andy? I'm great. Thanks for inviting me, Olin. Good to be here. And the associate trainee editor, Michael Waiteman. How are you, Michael?

SPEAKER_01 0:27

Very well, thanks, Ali. Also pleased to be here.

SPEAKER_02 0:30

And uh my name's Oliver Robertson. I'm the trainee editor of the journal, and we have a special guest today, Alicia Thompson, who is working up in Queensland, and we're going to discuss her original research today. Her paper is entitled Psychiatry After Hours: Factors Impacting Workload and Workflow. And it was her scholarly project that was published in the June issue of Australasian Psychiatry. So we'll put a link in our bio to the paper for this episode. So Alicia, welcome to the show. Are you able to give the audience a bit of an update on who you are, where you're working, and what's going on for you at the moment?

SPEAKER_00 1:09

Yeah, thanks, Ali. So I'm actually a medical administration registrar up in Townsville, North Queensland these days. I previously was a trainee with the Royal College of Psychiatrists and left at the start of this year, but did manage to get this publication prior to leave.

SPEAKER_02 1:30

The paper, I mean, reading it as a trainee really is obviously very relevant to trainee welfare and ties in nicely with what we're trying to do on the podcast here and that giving people resources and thinking about how they can best navigate training. Are you able to tell us how you came up with the idea and how you got started?

SPEAKER_00 1:51

This started many years ago. So I actually started working for mental health services in Townsville back in 2016 as a principal house officer, so an unaccredited trainee. And at that time there was a lot of talk amongst the registrars and consultants about the increasing workload in the after-hours space, the constant interruptions from the phone calls, and a lot of fatigue because most of it was performed as overtime, and yeah, and concern for well-being of the registrars. And we hadn't had a review of the system for many years. We just continued the same after hours on call system, even though we knew that we were probably seeing increased presentations to the ED, which that shift recovered. And so it was probably two back, yeah, 2017 that then I was on a return to work after having had some chemotherapy for ovarian cancer. And um the medical director at the time said, Look, I'm really worried about this. We don't really have any idea of um or any measurement of what's happening in that space other than you know, it is likely impacting well-being. Can you, you know, go and talk to the staff about what's happening in that after-hour space and try and find some recommendations for improvement. So I started interviewing uh registrars, consultants, the acute care team clinicians, nursing staff, and then put all that together in a large report and gave it back to the service group. Um a couple of years later, again on a return to work, the the next medical director said, Oh, that report you wrote a few years ago, there was a recommendation for a time in motion study of the after hours to understand what kind of what is the workload and what is impacting the workflow of those shifts. And so that's what led to the project. Um, and I should emphasize it was really a concern about the well-being of the registrars and and wanting to improve the service for the benefit of the staff, but also for patients and the care they were receiving.

SPEAKER_02 3:57

Such an interesting story. You mentioned that you were unwell at some point. Was that playing into it for you? Like was it um taking a toll on your own health being um pushed in that direction and having to do long-on calls?

SPEAKER_00 4:08

Or I suppose I was quite passionate about well-being because when I was first diagnosed, my diagnosis was delayed mostly because I was so busy and preoccupied with work. I really just didn't take the time to consider my own health. And so I would consider myself a strong advocate for well-being of doctors. And so that certainly has had an impact. And I was working long hours even before starting the on-call because it was, you know, it's I imagine it's common for many trainees around the country. Um, long hours, usually short staffed, um, busy units, not enough beds. So, yeah, it was a consideration.

SPEAKER_02 4:46

Yeah, I mean, it's such a rich um point to start a study from and have such um uh you know genuine motivations to try and um measure, measure the problem and and identify it so that um you can make some meaningful change. I suppose we'll um take that on board and then move more into the to the study and application side of things. Uh Michael, did you have any questions about sort of process and and how things were gonna move from there?

SPEAKER_01 5:13

I suppose the medical director came to you and said, this is a study I'd like you to do. What were your next steps from there? Is this something you'd done previously in another area, or did you need to go and then find a mentor to help you get started with this? What was your approach to getting stuck in and starting the study?

SPEAKER_00 5:30

Yeah, so after I was approached by the medical director, I went back to the original team that we'd assembled to look at the after hours system a few years prior. And so we sat down, um, had a look at the report that had been written and what had been followed up and where there were still some gaps. And um I found at that time that a lot of the people in that team didn't have a lot of research experience, and so they were trying to solve a lot of problems with one project. I had no research experience, and so it was actually quite overwhelming. Um, I was looking at what is a time in motion study, why did I write that in the first place in the report? Um and yeah, and so I was lucky enough to work for a service that employed an academic psychiatrist to assist registrars with their scholarly projects, and so I went went to Professor Brett McDermott and asked him for help. And so essentially from that point on, he was involved in the study design, the ethics application, um, later on the data analysis and the write-up. And if it wasn't for having Brett's support and it was also holding each other accountable, this project would not have been published. Uh, can't speak highly enough for having someone in your team with research experience because it took him to kind of, you know, wind some of the ideas back and kind of it almost say, look, you know, we need a narrower focus here. As it is, the project was quite large. The publication doesn't actually talk about the full scope of the project because there was a 2,000 word limit. Um, but yeah, I can't, yeah, get yourself an academic psychiatrist.

SPEAKER_01 7:09

Alicia, for our listeners who might not have heard of a time-in-motion study before, can you explain a little bit about um that as a concept?

SPEAKER_00 7:17

Yeah, so it it kind of covers a few different things. It's quite broad actually, but what it meant for this project is there was a few different elements, but part of it involved uh getting medical students to follow the registrar on the evening on calls, and in 10-minute increments they recorded what the registrar was doing, where they were located, any interruptions that occurred in that 10-minute period, whether that was phone calls or a nurse coming and tapping the doctor on the shoulder when they're on the ward. And so that was only possible because I actually got a grant and I was able to pay some of the meds medical students to do that. And um yeah, so then we essentially had that information which was then entered into Excel and then later exported to go into the statistics package. Um, I was planning on using technology for that, however, time limitations for the project and budget being able to purchase something or design something from scratch to be able to record that information meant that was difficult and not possible for this initial project.

SPEAKER_02 8:21

It's funny, I think after doing a few of these episodes now, we could almost do our own qualitative study and look at the sort of um common themes, but everyone has said that we should be getting uh support from someone who has a research experience specifically and not just a, you know, um a senior clinician or someone who's not as sort of research focused. No one as yet has spoken about getting funding or applying for grants as part of their scholarly project um process. Was that something that you knew you would have to do before you started, or is it during the process that you realized I need some money to be able to get some people involved? And what was that like? Like, how did you how did you do it?

SPEAKER_00 9:04

Yeah, so I suppose I'll um so when the medical director first approached me, it was to do the time in motion study, they didn't actually specify that I had to register it as a quality improvement activity or even do it as research. Um, I was kind of just asked to go do a project and that was it. And so, because of the previous experience with a project that hadn't led to permanent changes being made, I made the decision to try and improve the impact of the study to register it as a quality improvement activity. So that's where I started. And once I registered, I also sought to submit for ethics so that I'd be able to publish later. And during that, it was actually the research unit at the hospital that approached me and said, Hey, we've received your ethics application, your project sounds quite interesting. We have a grant round open currently for registrars for the purposes of completing their training. You can get up to $5,000. Please apply. And so when they come to you and ask you to apply for something, you know you've got a pretty good shot. Um, so I did the paperwork that was required. It wasn't a lot because I already had all the information um from when I'd submitted the ethics and the quality improvement register. So um we got the $5,000 and was, yeah, able to purchase some med student time, which was good.

SPEAKER_01 10:30

How did you find juggling um doing this project along with all the other requirements of being a trainee and all the other things going on?

SPEAKER_00 10:37

There was quite a lot of time lag from when I f when we first did the follow. So that was in the month of August. I think that was back in 2019, um, if I can recall my own dates correctly. But um, and then it wasn't published until oh well after that, and that was just because of that pull to your clinical area. So the project was done in August when I was still off clinical duties. So I was on the return to work at that point. And as the project finished, I think the last week of the project I returned to full-time training, full-time clinic workload, and yeah, hence a delay in managing to analyse the data and then write the publication. And it's probably one of the greatest challenges I faced was just trying to find that time in work. Obviously, a lot of it was done in my personal time, um, which, because I am an advocate for well-being, I'm always conscious to not lead, let work go into my personal life too much. So it was difficult.

SPEAKER_03 11:39

Alicia, I I have to uh full disclosure, we we have worked together and I was uh a somewhat awed observer through some of this, and there have been developments at Townsville as a result of the work that you did. But I think what you've talked about already demonstrates the value of taking a scholarly project direct from your working life because that's where you identify particular issues that have an impact on local culture and practice. And so um I know that you you're not with the service at the moment, but there have been changes in how things are done. Do you want to describe some of those changes?

SPEAKER_00 12:17

Yeah, so there was some early changes. We did look at a complete roster redesign and engaging the registrars on that. There was a few little changes to how the after hours is staffed, um, definitely trying to reduce some of that overtime. The information was all fed back to the nursing staff as well as the acute care team, as well as the service itself to try and improve that knowledge of that support after hours, um, trying to reduce some of the phone calls that were affecting the workflow. So the nursing staff were engaged through their leadership to you know try and reduce or minimize some of those calls that might not have been 100% necessary. Um, yeah, so there are definitely some changes, and currently in my role as the medical admin registrar, I've been involved in the implementation of a medical task management app. And I'm actually in the early stages of discussions with psychiatry to try and get that implemented into their after-hours service to be able to understand again what's happening with that workload, so then changes can be made, but also to try and improve that workflow, which was probably one of the biggest things that the study showed with the number of phone calls being received.

SPEAKER_03 13:36

Of course, as a director of training for the area, I get to talk to a lot of registrars and they they have mentioned that it does make a big difference when you're uh on a night uh duty. If if your phone calls drop from 30 down to five, and the five are the things that you actually have to deal with, that can make a huge difference to the night and allows you to get on and do the things that you need to do. I think I saw one of your early spreadsheets, and the amount of information that you were collecting was was quite uh substantial. How um with with Professor McDermott, how did you choose the things that would have the greatest impact to put into the article? Because there is a selection process there.

SPEAKER_00 14:16

Yeah, so there's actually quite a lot of stuff that's not published right now, which always makes me feel really guilty.

SPEAKER_03 14:21

Oh, this is this is going to be the next three papers, is it?

SPEAKER_00 14:24

Oh, yeah, there should be at least one other, but it's um just trying to find that time to get it done. But um, yeah, so we sat down and tried to look at what we're trying to say in the article. And so we decided that we really wanted to focus on why this was important. Um, we wanted to make sure that, because we were publishing in the Australian psychiatry, we wanted to make it applicable to other services who might say, actually, this you know sounds a little bit like what's happening here. What might we be able to change? And so we used the data that wasn't from the time and motion aspect itself, but more so about those the interruptions, so the phone calls, um, as well as the handover and that communication piece, and so focused on that because we thought that is probably what was having quite an impact on the registrars and how they perceived the service.

SPEAKER_02 15:18

Um Alicia, I think it's amazing. Like the um, I'm sure that your vision for its implementation and the changes it's going to make are sort of broad sweeping and trying to be delivered at a higher level. But I'm really glad that you've published the paper because as a registrar, even for myself individually reading it and reflecting on how I use supervision and noting that other um registrars around the country don't talk about after hours at supervision, it sort of reminds me to do that because I think it's an important part of the process and using after hours as a learning experience, um, I think to steal a phrase from you, not just a uh not just a service provision, um as a as a is is which is often how I see it, I think, um and potentially how other registrars see it. So I think the fact that it's out there and it's in the public domain and we can read it, it it means that the influence kind of spreads not just at an executive level, but um you know for the individual registers who read it too.

SPEAKER_00 16:21

Yeah, and I think that came from the initial work back in 2017 where so I actually analyzed the roster and looked at um who was doing most of the on-call. And we had um registrars that were doing quite a lot of on-call, but then we had others who were actually avoiding on-call um because they found that this the shifts quite stressful. And um, but what they hadn't considered was the amount of learning that occurs, and so for me it was kind of trying to take that focus away away from how difficult the shifts were and um that they were fatiguing and um and difficult, and actually say, Well, but you learn a lot on those shifts, and you know, can you be a good consultant? Can you finish your training without having, you know, done your fair share of on-call and you know being able to reflect on the experiences during those shifts?

SPEAKER_01 17:13

I suppose the point that you're making is that you can still get those learning experiences, but it'd be done in a way that's um not detrimental to the to the trainee in terms of work-life balance and those other things, and finding that happy middle point between the two.

SPEAKER_00 17:27

Yeah, so we said that the shifts were important, so we we put in that, you know, it was mandatory to participate in the on-call and put some minimum um shift requirements around that. But then I suppose it was about trying to say, well, okay, we've said everyone must do it, but how do we make the shifts better?

SPEAKER_03 17:44

One of the things I really like about the paper and how you've described it, it emphasizes the scientist practitioner role within the CANMEDS domains, and that you you can always be thinking about what you're doing, you have to think about the patient and the circumstances, but you can be thinking about the system within which it occurs. And so scholarly projects are not just about medication or randomized control trials, they're about all of the things that we do as psychiatrists. The role that you took in developing this paper and the related work that you've done does seem to lead very naturally onto your current role in medical administration. Do you think that that uh there is a link there?

SPEAKER_00 18:26

I would definitely have to credit this project work that started off many years ago as leading me to my current position. Um, when I started these projects, I was very set on psychiatry, and I still love psychiatry, and you know that Andrew spoke to you quite a lot before leaving the program. And um through yeah, through this work, through this project, um, and the the idea of quality improvement was really what fostered my interest in medical administration, and I've been lucky enough that this project actually got me recognition of prior learning with the Royal Australian College of Medical Administrators. So, although it was registered, uh well, was put down as a scholarly project for the College of Psychiatrists, this actually managed to meet the research domains for another college.

SPEAKER_03 19:16

That's a double score. I I actually haven't um given up hope that we'll get you back into psychiatry at some point and we'll have a um a gun administrator and a gun psychiatrist. But um, I guess that's a different path and that will happen down the track.

SPEAKER_00 19:31

Yeah, I definitely can advocate for mental health from my current role and future role.

SPEAKER_03 19:36

Very good.

SPEAKER_01 19:41

Alicia, what advice would you have for a psychiatry trainee who might be looking to do a similar kind of project at the moment? Are there things that you've learned through experience that you wish you knew at the start, or or what would you say to someone starting out now?

SPEAKER_00 19:55

I think I let time pressures get the better of me with the early design and implementation of this project. So I did go quite large and collect quite a lot of data from different areas, um, and a lot of it was manual. Um, so I think in the future I'd probably if I think the time frames are unrealistic, then they're definitely unrealistic. And I would try and look at what external pressures are being received to meet those deadlines and kind of try and readjust from there, as well as just knowing that a narrower focus when you're starting out in research is a lot simpler. I definitely was way too broad. Um, and thankfully Brett was able to bring it all back down and manage to get something coherent for a publication. Um, but it is also wasteful that I've, you know, I've got this data sitting there. Um, that was a lot of investment from the registrars and consultants that gave me the time to fill out surveys, to fill out sheets every single shift they did for a month. Um and so I think just trying to, you know, be a little bit more concise with what you're what question you're trying to answer. And do you need all the data or do you just need to focus on one aspect to be able to answer that?

SPEAKER_03 21:19

Did you consider any other journals other than Australasian psychiatry? How did you target that one?

SPEAKER_00 21:23

I went with what Prof McDermott said. I suppose it but it is the one that you know supports the registrars in their research and you know does have a line to be able to publish scholarly projects, and so that was the first publication that we sought to go for. And that's the the article was written for Australasian psychiatry with its submission um protocol and the 2,000-word limit.

SPEAKER_02 21:51

Alicia, there might be people out there who have also collected more data than they can use for their scholarly project or even a publication as part of it. Have you thought about potentially bringing on anyone else who might want to use that data to publish the paper if it's not within your job description or the time constraints you've got at the moment?

SPEAKER_00 22:12

Yeah, only recently did I think about even approaching possibly like another trainee about whether or not they'd want to write a publication from it. Um it's still kind of just something I've been toying with, probably only in the last month, because it's it's only been the last month that I've probably finally accepted that it's been a while and I still haven't managed to get this second publication written. Plus, I think it spurred an interest in me in quality improvement, and I've got some other projects that I'd really like to do, and um that are very relevant to my current role, and so it's kind of do I go back and analyse some old data to get a second publication, which would be interesting, or do I invest my time in these new projects which involve implementing a task management app?

SPEAKER_03 23:02

I'm picking up that you've you've caught the research bug that you're now addicted and um it's gonna be a lifelong habit.

SPEAKER_00 23:10

I think it's actually more of like a quality improvement bug. Yeah. So it's it's not the focus on well, I suppose it is to ask a question, but it's all based off trying to improve a service or trying to improve a system. Um and you know, again, it's based off that well-being interest in like doctor's well-being, but then also bringing it back to if we have healthy, happy, engaged staff, they're going to deliver better patient care. And um, so yeah, it's that kind of quality improvement angle that really interests me. But being able to share that with people and the way we do that outside of our local service is to be able to publish.

SPEAKER_02 23:57

I don't know about everyone else, but that I mean to me that sounds like a good point where we can think about finishing up. Alicia, as a team, we'd really like to thank you for coming on the podcast and um sharing your story and your scholarly project with the audience. Um, we wish you the best of luck in the future.

SPEAKER_00 24:12

And uh thank you, guys.

SPEAKER_02 24:14

Yeah, thanks Andy, thanks, Michael. Thanks, Ellie. Very nice. We'd like to thank David Beale at the College who supports the making of this podcast, Australasian Psychiatry for giving us the opportunity. There is a link to our intro and outro music in our bio, and thank you to Sidoni Printus for creating our logo. Uh see you next time.