Clinical Leadership and Management Roles for Psychiatrists – Dr Jenny Babb
Dr Jenny Babb was a GP who decided to do psychiatry training and has not looked back. She was the first Box Hill psychiatry trainee and has remained at Eastern Health in various roles including community consultant positions postgraduate coordinator training the current role as the clinical director of adult acute inpatient services and CL. In this interview, we discuss some of the roles that a psychiatrist might play and in particular the interface between clinical leadership and management positions that one might encounter as one progresses through one’s career.
Dr Jenny Babb is interviewed by Dr James Shelly. James is a Child & Adolescent Psychiatrist from South Africa, currently working with Eastern Health’s Early Psychosis Team in Melbourne. He has published work on methamphetamine psychosis and schizophrenia as well as treatment guidelines on ADHD and has been involved in expert consensus conferences on ADHD and ASD with the WHO and the Karolinska Institute in Stockholm. His main clinical interests include work with younger children with ASD as well as psychotherapy for anxiety disorders in children.
James: Today we can take it so speak, a bit of a proximal to distal kind of journey , in terms of the timeline of it of a professional career. Maybe starting with late trainee junior consultant, maybe if you could start by telling what do you see as the major roles and responsibilities of a junior consultant in an Adult Acute Inpatient Ward ?
I think it’s about them embedding their Clinical Skills in a way that’s different so it’s really in that transition it’s different that you’re taking more responsibility , there’s different forms you have to fill out so it’s actually getting familiar with the role and hopefully you’ve done some of that in your final stages and that you’ve had a good supervisor that’s exposed you to some of that.
But I think it’s really understanding those things and then it’s also then about expanding it out from there so being more understanding about the role within a service and the roles of the multidisciplinary team in meeting the patient sort of wider needs but how you oversee that to make sure all the aspects are covered. I think it’s about then as you feel more comfortable with having embedded that you can start to expose yourself to different service wide needs and think about beyond.
I think we’ve got really good solid but I don’t know whether we’ve had a lot of exposure to things like incidents and how we manage those. So I think most people do psychiatry cos they’re quite inquisitive about humans but I think that inquisitiveness then starts to expand a little bit further as you get more comfortable in that role and then it’s more about that service provision and how you use that wider team, how you are part of that service culture and respond I think in a different way.
So you can expose yourself to things like in-depth case reviews and RCA;s and different sort of systems review, you can be getting involvement in actually responding to complaints and running things. I don’t think you get that exposure as a trainee, that tends to be those roles of a consultant that you haven’t had a lot of exposure to. The really important thing is that you seek the right support, so I think is a junior consultant, you have to have regular supervision because I think there is a lot that comes up that’s quite anxiety-provoking because you’re now making decisions about risks, not just sort of doing the follow-up of what the consultant’s done.
I think that you’ve got to make sure that you feel comfortable in that system and that’s what I really encourage people to start on an inpatient unit when they start cos I think there’s always people around, you hopefully have enough support. It is pretty busy and it is the sort of pointing in but I think it does expose you to a lot of those things, it allows you to embed.
It’s almost like the OSCE training in practice and that people that have done those things many, many times actually do have a lot to offer. So you’ve got to seek out the right people and the right supports to make sure that you’re always feeling comfortable.
James: It’s almost like what you’ve described as the transition from trainee towards lead specialist on the ward, and then there’s a next jump to the leadership and management type roles.
But some of that comes into all consultant roles, I don’t think you can avoid it , and I don’t think being protected from it too much is actually helpful. So I try to involve, and I try not to sort of override but involve people in complaints and incident management because I think there’s a lot to learn from having that exposure and a lot of things happen after hours.
So I think the more that you can be supported within hours to understand all of those things as an after-hours consultant, then you are really left often to be the one in charge. There’s always some to escalate to, but sometimes you just need experience with different situations to feel comfortable with them, that just comes with time and doing the role.
James: Something I noticed going from the late stage of my training, is developing an understanding and a knowledge of all the behind the scenes stuff that goes on. So you spend most of your training time focusing predominantly on your clinical skills, but it takes a while to gain mastery of the clinical skills to then free up time to see some of the other trees or the forest as a whole. I guess that is something that comes with experience, because you do learn about it and get taught about it, but you don’t necessarily get to practice it until you until you’re in that leadership role of consultant.
Jenny: You often really do need to think on your feet and that does take a level of experience and it’s an awful thing to feel that you left with a lot of doubt so I think you just have to make sure that you’ve got the supports around you will seek out help when you need it.
James: I think at the level you are working now, you get faced to you a lot of complexity and ambiguity where specialists are being left feeling uncertain and then has to elevate it to that level.
Patients in general, we have a set formula and we know how to respond to things. It’s far more the systems and the transitions between inpatient and outpatient , its at those points we learn about the wider systems and how you can try and achieve the best clinical outcome, but also around the risk management sort of strategies and how we can only do the best we can do. But you do it enough times and it becomes just quite natural in how you respond to those situations, if that make sense”
James: I guess its about developing a broader knowledge about not just where this individual sits as an individual patient, but what’s the context in terms of what happens to them and their environment, and also the type of support we’re able to provide.
I think as a trainee, you only feel responsible for that episode of care at that time, but I think as a consultant, you think a bit more broader and how you wrap the service around. Usually it’s just around being a sounding board, they don’t need a lot of support around that stuff, it’s the other things that become a little bit daunting.”
James: There’s neuropsychology literature around how our cognitive skills and problem-solving skills change as we age and how our processing time and attention and memory are more accurate when we’re young and tend to decline as we age. I think what we’re talking about now is akin to that, when you’re young you can list all the biomedical details of agranulocytosis but you might not necessarily know what to do with someone who has a treatment-refractory illness or what the consequences and risks are of stopping their clozapine. So I guess the outcome comes with age and maturity and experience and developing and having access to more options in your problem-solving skills.
Jenny: Yeah absolutely, and I keep on coming back to knowing who to go to. So I often ask our Medico legal department for advice, I often go to the executive clinical director for some advice. If I’m not sure, it’s just good it’s always good to have those sounding boards in any situation and that’s one of the joys I think of working in a big system, that you do have all those things available.
James: To know and recognise your limits as well. That was a big lesson for me, particularly working in child psychiatry. So many times you walk out saying “i don’t know” and the thing that gave me so much confidence was eventually realising that if I don’t know, then most other people don’t know either. It’s kind of learning that is ok to ask for help, okay to approach other people and bounce ideas off each other.
Often, its also containing the system within that, so in public psychiatry we all work in teams. Certainly working in an inpatient unit, there’s lots of very junior grad nurses and trying to encourage their development is a really important part of our role as well as the junior consultants taking an important role in teaching and supervision cos you learn a lot from that.”
James: How do you manage that space? Managing relationships between different members of the teams and the way that you would interact with another consultant is different to the way you might interact with a junior registrar or with the wards occupational therapist. So as a manager or as a leader you need to be able to know how to measure your interactions with people in a particular way.
So they’re is a couple of styles in that. So I very much base my management and leadership on relationships. With that you need to then know the processes and what actually people’s roles and responsibilities are. It’s sort of above the line and below the line, so if you can have a bit of both you can usually then adequately manage most things.
Often actually with junior staff is helping them understand their roles and responsibilities and managing what your expectations are and not making assumptions that they know what those expectations are so clearly delegating roles and responsibilities around the clinical care.
Make sure that people feel safe and open enough to be able to ask questions and clarify things and I think they’re the really important roles to ensuring it works well.
James: So its about building a good enough relationship with somebody so that you know where they are on a personal level and that they know you are approachable. And parallel to that is understanding how the system works, understanding what somebody’s training has involved, what their level of competence is and where they fit within the system.
And it works really well when you actually see where people’s strengths lie and how you can utilise them most efficiently, you know then you can really tend to progress things very well.
James: Something maybe a bit more specific to psychiatry that’s around supervision of juniors. I guess your interactions with the multidisciplinary team, its leaderships, but more so management. Whereas, supervising Junior trainees is more a focus on a leadership role. What’s your approach there, what sort of principles are there in managing and supervising trainees and junior consultants?
All of the basis of supervision that you’ve just got to have regular times to meet I just think having that face to face contact ,and we all get really busy, but you can never underestimate just how supported people feel by having someone to spend time with, giving them a space to go over things, a reflection space.
You can have an Open Door policy but you’ve also got to manage your own time so it can’t be too open all the time. So it’s structuring in regular times and then being lead by the person because I think certainly I’ve experienced a range of junior consultants who have very different needs.
I think if they can be honest enough about where their anxieties are and focus on those things, and if you can set up a coaching style where they’re bringing things and your just helping them reflect on things, I think that’s definitely helpful. People have interest in different areas so it might be that people just really want to focus on clinical stuff very early on but then might start to be more inquisitive about different parts of why is the service responded in a certain way.
So I think then you go off depending on where their interests lie or just what they’re dealing with at that time, so it has to be really lead by them. You have to provide the space and ensure that there’s always a space that they can bring.
I think people think when they become consultants, there’s more or a role from entering around that career development and in the supervision around what’s happening within their sphere of work. So I think that’s optimal but we all get really busy and people tend to think I should be able to manage it.
So making time and availability is really important and I think finding the right people too, so obviously it’s always good to have a line of supervision but then I think in mentoring, it’s good to find people that you may have looked up to or that you feel have similar styles.
Everyone has different ways of approaching things, or even changing the way depending on where you’re at in your level of development, so there’s lots of approaches there really.
James: In my advanced training, supervision was much more explicit and I get purposeful particularly from one of my supervisors and I found myself learning how to be supervised as well. Rather than just going with nothing and seeing what came up, making sure I had topics to discuss and questions to ask, talk about things I was struggling with and even personal and professional development concepts to to discuss.
I keep little lists, if it pops in to my head and I think that might be good to discuss with a junior consultant. So I try and keep those things as well just so that it’s ,you know you need a bit of a space, but if they don’t have anything to bring up and they feel that their managing well but there’s always something to cover.
James: You can use that as a teaching space and provide support for acquisition. So this building kind of seems seems to fit the analogy for me because because the water is downstairs that’s kind of the work that’s on the ground or on the floor and, as a we’ve discussed, there is obviously other aspects to being a consultant psychiatrist on an inpatient unit and the bulk of the work there is about clinical skills and being face to face.
But then if we move broadly interface between of the clinical rolls and then the management and leadership roles, and about relationships and interactions with management to management level 1 discipline say within psychiatry them between psychiatry and other medical disciplines Could you talk a little bit about that kind of interface?
I think again its about building those relationship, but if we take the blinkers off, the focus tends to get a bit wider and wider so understanding how each part of the service has to interact so for example around access, so you know obviously an inpatient unit is an important part around making sure there’s enough beds for people in ED’s and so there’s often organisational priorities. So you need to to meet those and really seeing how the different parts of the service impact cause if you just thinking about your own little patch there will always be problems.
So if the community we’re short-staffed in some area, making sure once again the the needs my change as a result of that part of the service, someone needing to stay a bit longer because the resources aren’t there. So it’s just thinking more broadly and the interaction across the hospital.
When I’ve been at Upton House in particular in Box Hill Hospital has evolved over the years it actually wasn’t part of Upton House, wasn’t part of Box Hill Hospital when it originally started so we were really quite separate and over many years that I’ve been here and seeing how we’ve better integrated into the hospital and developed much better working relationships.
I think mental health is really quite well respected, we have some very good processes involved in a lot of areas now like around aggression management, and I think patients are more complex. So certainly the enrich of medical into our psychiatric wards has certainly improved over the time which it really needed to, but I think that also the CL services.
So I think it’s a really bidirectional thing and I think that people do really respect our input and we’ve got to be really proud of what we have to offer and I think then other people value and think our service has grown and expanded.
I’ve really seen that respect improve over the time and I have quite a lot to do with that, is it medical, is it psychiatric, so for example the head of neurology, I can easily ring her and just say we’ve had a bit of a standoff here. So once again it’s about developing relationships but you have to have the Clinical Skills to be able to have those conversations and be over things because relationships themselves will only go so far.”
James: You have to be confident enough in your knowledge in core issues to be able to argue a case that has a bit more waiting in terms of internal politics rather than particular clinical need. The system has to run well to effect on population level.
Even on an individual level, we had to advocate very strongly to get some medical needs met. I think people understand a lot better now that you know we’re part of the hospital, that the in-reach is the same as everywhere else and I think the organisation has given that as well, so I sort of feel confident if I thought someone’s need wasn’t being met that I could ensure that that would occur and escalate it to the appropriate people.
James: People working in mental health need to destigmatise mental health within the medical discipline as a whole, and to instil a sense in other medical disciplines that psychiatry is also one of the medical disciplines, and that psychiatric patients have their own rights, have their own co-morbidities that need to be addressed as as with anybody else.
I feel we’ve really worked hard at earning that respect over time. So I think we are listened to and I think that our voice on a high level as well as on the ground is really strong now. But I think that’s because we’ve worked very hard to ensure that we’ve got the right processes and that we stand up to all the systems, and once your respected you can achieve a lot.
James: On a broader level, if we step outside of just one health service or even one health system, what do you see the roles that psychiatrists might play in broader socio political systems?
The interface with the officer chief Psychiatrist or the chief psychiatric nurse, we have to report to them but also you know it’s not uncommon that we might get a complaint you know that’s come via the Department of Health or a politician, so it’s it’s lots of interfaces and it’s never great when it comes from the top down like that.
But it does expose you to how society views things. Our wards are becoming more acute and we’re getting more referrals, so the interfaces seem to be forever changing as well and I feel like I’m forever learning about those systems and how that’ll impact things like the NDIS introduction.
You really need to keep up with it because it really does impact on how we deliver services, how we allocate resources within the system, how we interface, so it is just a forever changing landscape.
James: It’s also about how we allocate resources nationally. There is a lot of talk around the concept of mental health and the economic burden and mental illness costs on society and that’s the common language that appeals to the politicians.
So they do require a large allocation of resources at a national level and that drive has to come from us, has to come from people at a service level, has to come from research into the burden of mental illness and it has to come from our role as advocates for the rights of people with mental illness and we kind of have to sell mental health and psychiatry to broader society.
In the big public mental health system, it really needs to have some time space to reflect on the strategies in how we move with that because if we’re purely just always being reactive, I find that’s not an efficient way so we need to, this is where at Eastern Health we have a dual governance model. So for example I work with the director of nursing who’s the associate program director for the acute services, and so we often need to make time to strategise about those things.
Which once again is not something we are taught about in medical school. But it’s something that say our program director, or people that are non-medical can often be better at or have different contributions. So it is about working well with our non-medical colleagues because if we don’t have those strategies right we can’t do agile properly and we can’t just work within our medical model in a sustainable way. So that sort of sustainability and strategising is a really important part.
The higher up the ladder you go, and it sort of even a bit beyond the OSCE because that seems to still be quite service delivery oriented at a junior consultant level. But you can see how it does, once again, gets broader and broader and you get to learn more and more skills and they’re skills that you actually need to to learn.
I am doing things that I never thought I would be doing but actually enjoy being part of different working groups and different strategies at a high-level cos it does allow you to think more broadly with really interesting people with very different ideas, and so I think it comes back to that original process that the way you start to think about things changes over time depending on where you’re at.
James: Within a broader society and environment, it has to be well integrated. As you go from the individual with one symptom to their families, their community to the system they live in, it expands and becomes more complicated as it expands. In a way this is just an extension of managing one person and all the assets around it, it expands with every link in the chain.
With the change in the environment, we’ve seen a lot of consumer and carer consultants come in where once again you know a decade ago, it was being talked about, you were going to conferences, but it’s a really well integrated part of our structure now, really seen as part of the treating team. So it really is always changing, and changing for the better.
I we’ve got to listen to what are quite a strong consumer movement is saying that they need, and I think sometimes you know some doctors do find it hard to move with that, we have got our set structures, but we do need to change with the times, particularly if you’re working in a system.
James: As much as we as a discipline are putting ourselves out there into the community, but what we’re also doing with the consumer movement is pulling the community into the system itself, and it becomes much more integrated.
That change will never stop, now with the most recent things, with the electronic medical records and changes in practice, there’s always something that forces us to have to up-skill in different areas and integrate new ideas and practices.
James: Is there a particular reading, listening, watching that you might recommend for people particularly around leadership and management within mental health settings or within medical settings?
There is a lot out there. There are some medical leadership courses. What I’ve personally done is actually had a coach in management, so it’s a non-medical person that I meet with fairly regularly who works with lots of people in management and leadership at Eastern Health and so understands the system quite well.
I found that to be invaluable and was something that was supported by the organisation to develop my skills. So I think it’s really once again, seeing what’s available at the local level and there is a lot because that career progression happens in all areas of the hospital and expanding it to just beyond the medical management because you can learn a lot from other disciplines.
Approaching medical leaders either within psychiatry, but it also might be outside psychiatry and how you can be involved in different areas and develop skills in different areas. So there’s a lot of quality improvement now whether that be review of adverse events or other sort of quality improvement areas.
There’s never ending opportunities in a hospital but it’s about doing it when you feel comfortable to take that next step and I think if you’re in a good spot of supervision or mental relationships, people will encourage you along those lines and you know when you’re ready.
Some people are not interested in those things so you know they might never be ready, but I was always really inquisitive about why people made decisions about the service delivery, so I sort of eventually wanted to be part of the decision-making and understand it and I found that really helpful personally, but I certainly understand why not everyone wants to do that.
There’s lots of very good teachers, you find the people who do good things and you work with them and learn a lot.