Medical Education, Entrepreneurship and Innovation – Interview with Dr James Shelley

WORK WEEK AND PROFESSIONAL LIFE

James – It might be nice, just in your own words, to tell us a bit about what your day to day or week to week professional life looks like because it gives context, I think, to the types of questions that I ask.

Sanil – Firstly, it is a great privilege to feature on this podcast, James. I think you’ve been doing a great job getting people’s thoughts through sound across Australia, New Zealand and the world, so congratulations, great job with that.

I am Sanil Rege, Consultant Psychiatrist.  In terms of day to day, it’s always been a bit tough because I’ve always been the sort of person that is quite scattered, so I don’t really have one routine through the day, but if I had to break it down, there is the academic and the business side of things in terms of clinician and the business person.

You might think of me as an educator, as a clinician, and of course, an overarching entrepreneur, if you want to put it that way.  When we come to talking a little bit more about entrepreneurship, in the traditional sense, people often think of entrepreneurs differently.  I tend to think of myself as an entrepreneur clinician; everyone really is an entrepreneur in their own sense.

Three roles:

So, they are really my three roles.  The way it works really depends on what is happening most at this point in time.

The academic: For example, around the times of courses, I will be focusing a lot more on Psych Scene and getting the written course material for the essay, the MEQ, the EMQ and the Critical Appraisal aspects ready.

The clinician: In my clinical day to day practice, I’m practising at least two days and that will increase or decrease depending on how much extra academic work is required at other times.

In terms of my clinical practice, I’ve set up the clinic – Vita Health Care – a group of Psychologists and Psychiatrists.  We are six Psychiatrists and six Psychologists and besides the community side of things, which is Vita Health Care, I admit patients to Beleura Hospital for inpatient psychiatry, alcohol rehabilitation and consultation-liaison for any referrals from Physicians.  So, it is a scattered clinical variety but keeps me really stimulated and fits in with my personality.

The business person: From the business side of things, I would possibly allocate maybe 1 – 2 days per month to look at things strategically; most of it is not really detailed, it is really taking a step back and visualising how things are going and where things need to move forward, discussion with the Business Development Managers respectively for Psych Scene and Vita Health Care and just see if things are tracking well.

THE PATH TOWARDS BECOMING A MEDICAL EDUCATOR

James – It’s nice, for creative people and intellectually curious people, to have a varied mode of working because as you say, you find different aspects stimulating in different ways and it is good to be able to chase that all the time. 

We won’t spend much time talking about your clinical role because what strikes me is the more unique part of what you do is the educator or academic role and your ideas around entrepreneurship. 

Firstly, around the academic and educational side, what do you think it is that drew you towards the path of education within the medical field or within psychiatry?

Sanil – As with most things in my life, things have come about serendipitously, so I would say I found myself as an educator very serendipitously.  I trained in the U.K. and in the U.K preparing for the MRCPsych courses, it was almost tradition to attend a few courses that would prepare you for respective exams.

Being a curious personality, I would attend quite a few courses just to see how things are being delivered but also, I think when things are delivered in different ways the information tends to stick; repetition is one of the ways of learning and consolidating memories.

So, attending lots of courses was something that I did quite a lot of in the U.K. but I never really thought of myself as utilising any of that for the future.

After I completed the MRCPsych I made the move to Australia, which again, in many ways was not a planned move, it just really happened with modernising medical careers and the change with the NHS.

So, I found myself in Australia and having to do the exams again.  Having completed only 3 ½ years and getting my MRCPsych within that period, of course, meant that the College required me to complete Consultant Liaison Psychiatry and do all of the exams.

I decided, with my Director of Training, to complete the exams in a year and a half and they were, of course, the same components: the essay, the MEQ – there were key feature questions (KFC) and short answer questions (SAQ) as well during that period – as well as EMQ and Critical Appraisal, and then, of course, the OSCE and the OCI as well, which was the long case.

I guess at that time it was quite daunting in many ways but at the same time I liked the challenge and I love learning.  I really enjoy reading – I do lots of reading generally, as well.

So, it kind of fit in quite well, there was an aim and I decided to get through all of that in a year and a half and was able to get through all of the exams the first time.

Once I finished, there was a lot of influx from the U.K. with lots of other doctors who had come over as well and I remember Professor Nagesh Pai, who was also doing the long case at that time and he had got together a group of people who were doing the exams and said, “Sanil, you’ve got through the exams, do you think you could give us an outline of how you went about the long case?”

So, that was my first foray into structured teaching – I got the slides done at that point and I did a day course for eight or nine people and at the end of it the feedback was really good and Professor Pai said, “Why don’t you make something out of this?”  That was my first idea of it.

I came back and put some thought to it and spoke to Jaana, my wife, who has a Business Marketing background and she encouraged me and said “If you’ve got something you feel you are able to impart and do it well then I can support you.”

We both had our day jobs; me as a Clinician and she had a job working in tourism, and that was our first ‘Eureka’ moment, where we thought about creating the business.

Initially, we started off just with the long case – the OCI courses – and we got a lot of feedback and continually improved things as we got the feedback.  We used the testimonials from the individuals who had attended the previous courses as marketing tools for the others.

Personally, I put in the work in terms of setting up and populating the website, reading about SEO, marketing and how to set up a business,  all of those basic things that we don’t get taught about.  We created the brochures; I would go and hand-deliver the brochures myself and send emails across to services and that’s how it grew.

So, I found myself as an educator and once there is an audience, of course there is that pressure on you having to deliver well and improve things and I think that circle of quality improvement – if one puts it that way – was set up; the framework was created.  It was called “Cruise through the Fellowship” then.

The first approach to set up the business was to the service in which I was working and I said, “Would you like to support this?”

The second approach was to look at another organisation but both of them really didn’t take it on board and that’s when I decided to take it to an individual level.

Interestingly, the service came back later when it was set up to say they would like to partner but by that time the boat had sailed and that was the birth of me as an educator in many ways.

THE ROLE OF A CONSULTANT PSYCHIATRIST IN EDUCATION

James – It’s interesting, you mentioned, in the beginning, the idea that repetition helps us to remember; I have done a little bit of teaching when I was doing Child Psychiatry – it was a joint position with the university, all of the speciality training in South Africa is done through the universities – and I found that teaching really helps you to refine your thinking because you are repeating things but each time you repeat them you want to find a way to phrase it just a little bit more succinctly, that really distils and refines your thinking.  It can be a really good learning tool being a teacher. 

Psych Scene runs courses for a variety of professionals, from psychiatry trainees to GP’s.  How do you see the role that a Consultant Psychiatrist should play in educating trainees, specialists, GP’s, other mental health and medical professionals?  We’ll get onto the public at large but first, within the medical profession.

Sanil – Coming back to an early point where you talked about teaching, I think it was Einstein that said:

If you can’t explain it well then you haven’t understood it well.

I think teaching is one of the most powerful ways for oneself to know whether one has understood the concept well.

Digressing a little bit, I will come to the question because it is really important, I believe that everyone has an educator inbuilt within themselves, we have that capability, it is just really about whether we are being explicit or whether we keep it within ourselves.

Even when we think about techniques to improve learning, one of the powerful techniques is from Richard Feynman – the Feynman Technique – who was a Physicist and he said to think about a topic and the next step is to be able to explain the topic to a layperson or child.

When you are explaining it to a child or a layperson, you have actually got to think about how to communicate it in the simplest possible way.  Simplicity is one of the highest forms of genius.

Being able to break it down and then identify the deficiencies as to – Where is that communication gap?

If the person on the other side isn’t quite able to get it,  you do find, as you mentioned, those different ways of expressing it and that is where the real learning happens.  Through those small changes that you are making, new insights are created and you refine that and then continue with the loop, which is to move on to other topics.

I think everyone does this through medical school anyway but the question is whether one is learning it through rote learning or whether one is really understanding the concept and this comes to a certain kind of knowledge.

Knowledge is divided into Planck Knowledge (Max Planck) and Chauffeur Knowledge.  There is a really nice story about Max Planck who used to go and talk about his particular field across the world and his chauffeur used to attend all of his talks and had obviously attended so many of his talks that he was able to now rote learn the whole thing and deliver the talk.

So, at one particular event in Europe Max Planck said, “you go and deliver the talk”. So, he gave the talk to the public and someone from the crowd asked him a question and obviously the chauffeur didn’t know the answer to it, so he said, “that question is so simple that I am going to defer to my chauffeur” – who was Max Planck – to answer it.  This highlights that when we are learning we have to be very, very mindful as to whether we truly understand the concept.

Coming to the point of where does a Psychiatrist sit in terms of being an educator?

The first thing we have to realise is that because we have learnt, we have got the educator capability within.

The next step is really in terms of communicating that to other Psychiatrists, other medical specialities, mental health nurses and psychiatry trainees.  Each one has a different level of understanding and experience and therefore, adapting that knowledge sharing, that osmosis, at different levels becomes crucial.  That’s where the real art is.

We do this day in day out when we talk about supervision.  Even when the Psychiatrist has a trainee sitting in the ward round, that is education.

Education is happening all the time; when we are communicating to a mental health nurse about the plan, that is educating.

The way I look at it is that in every sentence we are actually communicating something and there is the possibility of really educating the person at the same time.

We might say, “I am going to prescribe XYZ” but by just adding the justification for why we have educated.

So, I think a Consultant Psychiatrist plays a very, very important role in being able to impact patient care every minute that they are interacting with someone else.

ROLE OF THE PSYCHIATRIST IN PUBLIC MENTAL HEALTH EDUCATION

James – I think being aware of it adds a layer of responsibility to what you do because there is almost a layer of oversight.  Everything you say carries weight, everything you say is important in your professional capacity.

Keeping in mind the idea of having to tailor the way that you deliver the message between various levels within a mental health setting or discipline, what sort of role do you think we play then in educating the public at large about general mental health, mental illness and psychiatry in general?  It is a very controversial topic or discipline. 

Sanil – Psychiatry is one of those fields that intersects a lot with the socio-political landscape, culture, society and media – the sorts of things that are tested in the exam – and that is what makes psychiatry really fascinating.  So, as a result of that, I think we play an extremely important role in educating the public.  The public might be the layperson, the politician, or a sociologist – it could be absolutely anyone.

We do know that the mental health burden when we look at statistics, is on the rise.  It has huge economic implications, huge social implications and health implications, of course.

As a Psychiatrist, when we think about how much we are out in the media, for example, promoting this, we don’t see ourselves doing that a lot.  We have got an advocacy organisation – the RANZCP – which tends to put out position statements and interact with politicians and the Department of Health and that’s where it stops.

The question is, is there sufficient mental health literacy out there in the community?  If one asks me that question, I would say no because when you look at social media, for example, Twitter or Facebook, you have influencers that play a huge role in influencing what mental health is, or even the notion of mental health.

When people talk about anxiety, people with lived experience it is important, but these are the greatest influencers in our time at the moment and these are non-specialists and they are providing a certain idea about anxiety that might not actually span the entire spectrum.

As a result of that, you have the possibility of misinformation, where patients feel that because this person has overcome anxiety, that I should be able to do it.  Because this person has overcome psychosis and achieved a certain recovery goal, which might be going back to work, I have got to do it; which might not be possible in this particular patient because they have a different spectrum.

I think as a Psychiatrist, we are in a unique position to be able to outline the entire spectrum of disease or disorder for the public and I think that is not done enough. It is a difficult one to do because of course, we are limited at times by patient confidentiality, we are limited at times even by anti-psychiatry sentiment, so there are a lot of challenges for us.

Some of this has been counteracted by some really good Psychiatrists, for example, Dr Mark Cross who had the ABC program; Changing Minds, which is absolutely brilliant, that filmed patients in a tertiary setting in Liverpool Hospital to show the severity of those illnesses and the kind of challenges that people face.  We need more of that for individuals to be able to see the entire spectrum.

For example, on Twitter, there was a debate about depression and a certain group of Psychologists that one may outline as anti-psychiatry – not in a derogatory way but one may conceptualise it in that way – claimed that ECT “causes” permanent brain damage.  These sorts of sentiments can be really damaging but they play a very important role because there aren’t that many potential Psychiatrists on Twitter that might be counteracting that sentiment.  This is just one of the examples; some of these Psychologists may never have encountered a patient with catatonic depression but they act as a major influencer.

To summarise, I think as Psychiatrists we play a very important role in educating the public but I think it can start in day to day life.  For example, around a family dinner or a social environment when someone passes a very blasé comment about mental health, I think it is important for us to be able to stop and to educate that person right at that moment about what mental health isn’t.

Words like “crazy” or “nutter”, all of those things can be addressed at a small scale because all change starts off small.  When one is with their own family members and certain comments come up, that’s where it can start because it makes the individual stop and think the next time they are saying something about mental health patients.

 

NOT JUST A LECTURE

James – So, it’s not only about standing in a lecture in front of an audience and handing out the facts, there is much more of an interactive nature to it as well.

Sanil – Absolutely, because there are different forms of learning.  We talked about repetition; when we think about how we learn, there is short term memory and long term memory.

When we think about long term memory, there is the implicit memory or the procedural memory and we have the explicit or the declarative memory.

Both are two completely different sets, so when a Consultant Psychiatrist is sitting with a trainee and interviewing a patient, there is a whole lot to be learnt in the interviewing skills, those nuances get picked up, like a role modelling aspect.  That is implicit memory, that stays with the trainee for a very long time.

For example, when I was training for my OSCE in the U.K, one of the things I would do with my Consultant was every morning before a ward round or before the session started, we would have half an hour with the Consultant and I would tell the Consultant, you can come up with any scenario, give me the one minute spiel and I will act it out with you.  That was our routine three times per week.

There was learning happening, the Psychiatrist is acting as an educator but it is not a formal session. It is experiential learning, which can be really fun.

CORE OF EDUCATION - COMMUNICATION

James – That’s something that has struck me.  Obviously, the more explicit learning from a book is critical, you have to have some sort of baseline but learning by emulating others, that experiential knowledge, for me has been so invaluable.  I often catch myself doing something or saying something in a particular way that I know I am emulating someone else, one of my role models from my training.  It is important for us to be able to conceptualise that as part of our roles.  You don’t necessarily have to split your career into clinical or teaching because even in your clinical role, a part of what you’re doing in your role is an educator.

Sanil – With patients, day in day out when we are communicating a diagnosis, that is education.  We might just go to the core of being a human, the fact that we are able to communicate – which is unique to our species – through more intricate speech, which means that we have got the flexibility to do things in different ways to individualise it to different levels of understanding.  That is unique to us and is a power that we can utilise for the greater good.

 

PUBLIC OPINION AND PSYCHIATRY

James – In some way it also comes down to tailoring the message depending on where you are and what your audience is. 

I’m glad you brought up the concept of the media because we live in a time now where absolutely everybody has immediate access, not only to a lot information – good and bad – but to a platform from which to express their opinions, perspectives and ideas.  Most people won’t have an opinion on cardiac stenting; I’m a doctor and I don’t really have an opinion on cardiac stenting but everybody and their grandmother has an opinion on mental health and with this platform, upon which to voice that opinion, there is a potential for really good information and critical thinking skills to be promoted but there is also the potential for real harm to be done. 

I like to think about what can we do as Psychiatrists to try and promote and propagate good, valid and reliable information about mental health, psychiatry and psychiatric treatments in a responsible way?  We have a greater responsibility than to just our individual patients, if you look on a macro level you can affect really widespread population-based conceptual change at least, through the use of these types of media.

Sanil – I absolutely agree with that, particularly when you talked about the cardiology example, I think that’s a great example because as Psychiatrists, we are a group that – to generalise – tends to be polite and mindful and not that brash, so, therefore, sometimes we think twice before really counteracting a certain sentiment.  We allow things to pass and accept a lot more.

I think it’s the nature of the role as well; we tend to accept a lot more uncertainty, we tend to accept more differing views because we know that the only certainty in psychiatry is uncertainty.  That can be extrapolated to the world, generally; uncertainty is everywhere.  So, as a result of that, we take on differing views.  Whilst in medicine, an opinion on a certain aspect could be slammed down very, very quickly.

For psychiatry, of course, some of the major events around the world haven’t helped – for example, the Chelmsford deep sleep scandal – and obviously this decreases the trust.

When you think about Nazi Germany, psychiatry played a big role, particularly in the Holocaust, with a large group of patients that they were responsible for signing death certificates etc.  That, of course, decreases the trust.

So, there have been stories that have led to society being sceptical of psychiatry, which is very understandable.  Besides the regulatory authority, you have society as a regulatory authority as well, which is not a bad thing but at the same time, I think we have got to be proud of the field that we are in and at times need to be very confident and shut down misinformation clearly and confidently.  I think there is a place for that.

There are debates around antidepressants, there are debates around ECT and of course, we know that we don’t have a 100% response rate with any of these things but we do know that these aspects work and for every decision that we make in psychiatry we employ risk-benefit analysis that’s individualised to the patient and we seek advice etc.

So, I think for individuals to even know the framework in which we operate and how we think is important.
On Twitter I have seen reference to ‘brain pellets causing suicide’, ‘ECT causing brain damage’, “frying the brain”; all of these things are really emotive statements and create a negative association for psychiatry as a whole.  I think being firm about it and outlining the framework in which we operate goes a long way in building confidence with the public as well.

I think that’s happening over time; mental health is very much in the media and people are talking about it but I guess, the spectrum matters because we don’t have the message about the severe end of the spectrum really out there.

When I say the severe end of the spectrum, I haven’t come across a patient with catatonic depression who has recovered and is out there in the media talking about it.

Where the patient is saying, “ECT has helped me”.  Or a patient with schizophrenia.  We do have patients and celebrities with bipolar, so I think it would be great for the public to get a feel for the entire spectrum, as opposed to just snippets of it.

This will change over time.

James – They talk about the power of gossip.

Sanil – Yes.  Stories.  Evolutionarily, stories are so powerful.  Even when we think about children and when we are reading stories, it’s all education, they are learning all the time through play or through speech and of course, reading and writing and all of those fundamental things.

I think for a Psychiatrist, you have a core role as an educator and we don’t even have to think about it as a role.  We are all educators; we are doing it day in day out.  It’s just whether we are really mindful of it because once we are aware of it, we tend to do things differently.  So just the awareness is crucial at the start.

COUNTERACTING NEGATIVE OPINIONS IN PSYCHIATRY

James – There is a lot of misunderstanding, a lot of misinformation and a lot of really irresponsible reporting that goes on.  A lot of it is linked to psychiatry’s dark past, a lot of it is just sensationalism in the media, it’s clickbait. 

I think we are also primed, evolutionarily speaking, to be more sensitive to threats and to danger and negative aspects of life than to the positive ones.

As you say, I think it would be a really useful thing to have good news stories, more of those than the bad news stories.  I was listening to somebody talking about this concept before about how the news generally only reports when things are going wrong or when something is happening. You don’t have somebody standing in downtown Melbourne saying, “there’s no civil war on today”. 

Nobody wants to hear about that, you want to hear the sensationalist stuff and I think that perpetuates the stigma within psychiatry. 

Sanil – A great example is the difference in marketing between cancer and mental health.

I pose this question at the courses, particularly when discussing the critical essay, relating to media marketing; we have got to think about challenging stigma, we have to think about propagating mental health literacy as a form of marketing because that’s really what it is, influencing people with the right kind of information.

When we think about cancer, for example, I ask the question and lots of times the kind of things that come up are the colour pink – pink ribbons and pink balloons – symbolising happy associations.  Then I ask the question, “what do you think about when you think about mental health?” and the first things that come up are black cloud and black dog.

It fits in with what you were talking about in terms of the negative associations and you can see clearly here, the associations with mental health just tend to be very, very negative.

Cancer is a condition associated with mortality with a range of cancers; yet, with schizophrenia people die 20 years before the general population as well, it is a highly debilitating condition in itself but there are two different forms of marketing.

It would be great to have good news stories, as you say, to be able to say, “this person recovered from depression, this is what was needed, these are the challenges” and giving a balanced view on how people get better and that each person’s journey is different and one can’t take a single case and sensationalise it.

There was a recent article in The Guardian about two deaths in the U.K. relating to clozapine, which was a very irresponsibly written article that really vilified clozapine, even though studies have shown that clozapine decreases all-cause mortality in cohort studies of thousands of patients.

These were two cases where reading the article, you could clearly say I can’t understand how this could happen with all the frameworks.  Unfortunately, it did, but systemic failures are more likely to have led to this, rather than clozapine as the medication.

So, these are the sort of things that need to be counteracted, but then when you have a newspaper like The Guardian having a storyline like this, it, unfortunately, has a much greater impact.

James – So, it’s finding a way to communicate reliable, valid and helpful information en masse but with the right kind of marketing. 

Sanil – Yes, and it comes down to being an educator at the end of the day as well.

INFLUENCES SHAPING OPINION ABOUT PSYCHIATRY

James – The right message but delivering it in the right way because that’s where the idea of adapting to the notion of being a psychiatrist, a professional, but also in the modern world and the modern environment, which demands a bit of a different approach to the way it used to. 

Particularly with the recovery movement; something that the media has created and the internet has created, is that it has flattened the playing fields in terms of whose opinion is more or less valid and whose opinion should be more or less followed.  There used to be a much more strict hierarchy in terms of if you were a specialist then you had a lot of clout, you were the most knowledgeable person on an issue, whereas nowadays we have to really think about it and work harder at marketing our ideas, in selling good information to people.

Sanil – This is where, although – as you mentioned earlier – the internet, the media, social media etc. can be used for the greater good, it is going to take a lot more cognitive effort on each individual to be able to weigh up the pros and cons of the message.

What happens with media is that we can be easily seduced by the charisma of the individual creating all of these cognitive biases, authority bias comes in, appearances can influence and associations of the individual to influencers.

So, there is a much greater onus on each individual to be able to focus on the content, rather than just the messenger.

Otherwise, it is no different to the sort of influence that happens in the phenomenon of a cult, of the Messiah being able to influence a whole group of people through charisma and through almost repetitive messages – propaganda, in a way.

There is a whole range of other variables that come to play now with social media and the exposure to the internet.  We spend so much time on the phones now, where subliminal messaging plays a big role.

ENTREPRENEURSHIP AND MEDICINE

James – So, striking a balance between charisma and content is really important.

We’re always going to be involved in education to some extent and so far we’ve mostly been talking as an educator, but it is a discipline that demands continuous professional development.  I also found that as a learner, media has really changed the way that I learn as well.  

We’re of the same generation; when I went through medical school I learnt with textbooks and by the time I was doing my final psychiatry exams and my child psychiatry everything was online, I had a few digital textbooks and one or two things that I just had in hard copy but all of my learning was done online.  Of course, by that stage, I had learnt how to source reputable material and I had learnt how to critically appraise information very well but even thinking now in terms of the exam that I just did that sparked the idea for this podcast, I did all of my preparation just by listening to people’s conversations and podcasts. 

So, the media and the internet has really changed the way that we digest information and the way that we learn as professionals as well.  I guess we are as much a target as we are a source of the information.

I thought media was a good segue between your role as an educator and some of the other concepts because you use a lot of media; you have your website, you have your blog, you use Facebook and Twitter, you’ve got the Psych Scene Hub, and in fact, that’s how I came across you and learnt who you were, so it’s obviously a very important platform for getting the message out there.   

What I want to link to there is your ideas of entrepreneurship and the idea of Psychiatrists or doctors, in general, having a clinical role but then having other interests as well.  The idea of a Psychiatrist as a professional and what that entails.  I wonder if you could talk a little about your interests in entrepreneurship and how you link it to your medical career?

Sanil – Again, just like an educator, I think the way I see clinical work, entrepreneurship, educator; they are all interlinked.  I am a big fan of making connections because ultimately you are trying to extract synergies between different roles.  The maximum synergy is obtained at the intersections of different roles.

To give you an example, as I said, every Psychiatrist has an educator embedded within him or her similarly.  Every Psychiatrist is an entrepreneur because if you look at the definition of entrepreneurship, an entrepreneur is someone that will shift resources from an area of low productivity where things are inefficient, to an area of high productivity.  So, just increase the yield of that same resource.

Entrepreneurship, therefore, is linked to innovation because an entrepreneur tends to then use certain techniques that are generally not thought of, or if thought of, not implemented and that’s what innovation is.

What the entrepreneur is trying to do is to endow that resource with a new capacity because when you endow the resource with a new capacity to create wealth – that wealth might be monetary, it might be intellectual, it might be social, it might be any of those aspects – that is basically the process of entrepreneurship; utilising innovation to create a resource that has greater potential.

If you think about Psychiatrists, a Psychiatrist is doing exactly the same thing with our patient.  What we are doing is to endow our patient; we are trying to move the patient from what we call illness, which is a low productivity area, to a high productivity area where the individual becomes much more capable of contributing to themselves, to their family and to society.  So, low productivity to high productivity and how is the Psychiatrist doing it?  They are using the process of innovation.

Our innovation lies in our thinking.  That’s where the formulation comes in.  We are thinking about the biological, psychological, social, cultural, diet and lifestyle variables, how they intersect, how they play a part and we try to then modify these variables to enable the individual to reach their potential.  So, we are basically looking at all of these variables, seeing how they are leading to disorder, modifying them and allowing the individual to reach their potential.

What I’ve just described is nothing but the process of entrepreneurship, except at the patient level.  So really, if we think about ourselves, we are doing this on a day to day basis.  But what has happened is because of tech, Silicon Valley etc., one tends to think about entrepreneurship very much like a start-up, funding, seed capital etc, which is linked to money but that’s not really what the traditional definition is.

James – Or the conceptual principle.

Sanil – That’s right.  The conceptual principle is simply a resource.  Now that resource can be a human resource, a technological resource, it can be a mechanical resource, it can be absolutely any resource.  Mining, that’s entrepreneurship; a mine being converted from unusable into a usable mine.

It’s there, everywhere, what you’re doing at this point in time with the podcast is exactly that; converting it to a high productivity area by spreading people’s collective wisdom.

When one thinks about entrepreneurship and innovation in that sense, one is actually becoming aware of what they are doing on a day to day basis and are then able to utilise different ways of thinking, different ways of doing, to change patient lives and to change systems as well.

One of the things that I would really like to have happen in psychiatry training is to be able to have some sort of entrepreneurship or business understanding for three months, or some exposure for a Psychiatrist because ultimately when we become a Consultant Psychiatrist we are then confronted with this whole systemic aspect, which we have never been familiar with and therefore struggle to change systems at times.

THE BALANCE BETWEEN BUSINESS AND BEING A CLINICIAN

James – They tried that at my medical school, we were the first ones they had tried it with; they gave us some sort of practice management course but they presumed that everybody in the class had done high school accounting and most people hadn’t because they were in medicine and everybody failed the course. 

It is a really important idea to teach [these skills].  You’re not just preparing people to sit in an office and do clinical work anymore, that’s just not how this modern life works.  You need to be able to prepare people for all that a modern professional life entails.

I think more than that, if you want, you can work in a practice or in a hospital and just see patients and that’s all you ever want to do, but coming right back to the beginning of the conversation around people who are creative and have this unquenchable thirst for new experiences and new knowledge and new paths to follow, I think we need to be preparing people for diversity of activity in their professional life and in that, it is about learning how to balance things.  How to value yourself and your professional knowledge so that you can sell yourself but then also how to be cognisant that you are representing your discipline. 

When you are out there in the media or whatever else it is that you’re doing, you’re advocating for the rights of the people you treat because as a Psychiatrist, by proxy you are an advocate for people suffering from psychiatric illnesses. 

For you, in your experience, how do you balance those issues?  Most people working in the health discipline are generally quite altruistic, so on the one end of that spectrum you are a martyr; you work all day and all night, versus on the other side, you could run a private enterprise that is linked to your professional life.  The other side is being quite exploitative; overcharging people, not giving them the right service unless they pay the right fee.  I guess it comes down to an ethical question: how do you balance respect for yourself as a professional with your will to do good for people?

Sanil – I think it very much comes down to the individual. I believe integrity in any field is absolutely crucial and I think this is ingrained, but of course, people learn as they go along.   It’s almost like when we talk about the superego, to really know what right and wrong is, that’s where the ethical principles come from.

Traditionally, in medicine, if one thinks about just the Kantian perspective and then the utilitarian perspective there is a dilemma because on the one hand, from the Kantian perspective one would say:

I am only going to act in the best interests of the patient and do whatever it takes because I have a moral obligation.  I will do whatever it takes to only focus on that one patient.

And that is morally appropriate.

But on the other hand, when you look at the societal perspective, if I transfer all of the resources available for this one patient, it will take away from societal resources, so I am conflicted with the utilitarian perspective.

That’s why Beauchamp and Childress came up with the wider ethical principles of beneficence, acting in the best interests, do no harm, justice and of course, the principle of autonomy, privacy and confidentiality.

So, you have the patient in the centre with the autonomy, respecting privacy and confidentiality and then weighing up the risks and benefits because we know that it is never that easy.

And then on the other hand, nowadays as a doctor we intersect with economic systems – there is just no way around it.

Even in the public system, we intersect with economic systems. Take, for example, the KPI’s.  If we have a KPI which we are trying to meet and the patients are being discharged before their remission because there is a huge burden, we are creating a “revolving door scenario”.

That scenario may not be immediately recognisable or confronting for the service but it does affect society.  So, we do intersect with the economic systems in a way that that patient’s potential to contribute to society has reduced, so money has been taken away in some way from society, through an intervention from hospitals.

When we think about private practice, traditionally we tend to think private practice is all about economics and money and public systems are different, but it’s not.  Ultimately, every decision made by a public system Psychiatrist still affects society.

So, I think having this dichotomy is, in a way, unhelpful because if a public system Psychiatrist also thinks along the same lines, then the partnership is much more likely between the public and private, where one is able to say, I am discharging this patient because we don’t have enough beds or due to KPI’s etc, is it possible for the private system to be able to take that on board, or this patient be seen more often or something along those lines.  That creates a better efficiency, as opposed to simple discharge, where the money has still been taken away anyway because the burden has increased.

I think it is not that clear cut.  In a private practice scenario, there is a greater skin in the game for the Psychiatrist because if a private Psychiatrist owns the practice, they really are confronted with all of the things that are happening in the public system, except that in the public system the individual doesn’t necessarily have their own money invested.  That’s the difference.

In a private practice, the individual has to think about staff costs, they have to think about lease, they’ve got to think about the software that is going to be used so that GP communication is optimal.  In private practice, the lease and staff costs contribute probably 75-80% of the bulk of the outgoings, so it is not an easy thing to balance.

At the same time, in terms of charging patients, that’s where the challenge occurs because on the one hand, if one considers only bulk billing, from an ethical perspective it is great because patients don’t have any outgoings, but the question is, is it sustainable for the practice?

The practice may survive for two years working on a Kantian principle – moral obligation, do not charge patients – but then what happens is two years down the track, the service can’t survive, becomes bankrupt and then societally, from a deontological perspective, the service has gone.  So you’ve got thousands of patients without a service now.

You can see that it is a very challenging situation.  Therefore, the balance might be having a dual model, where exceptions are made, where patients are bulk billed because the need is truly there for those patients, but the other patients are charged because that subsidises patients truly in need.  That is the sort of model that we have at Vita Health Care, for example, where personally, lots of patients are bulk billed.

This is, again, innovation, if one wants to call it that.  By being too rigid one way or the other, if we say we are going to charge every single patient, then there is a group of patients that won’t be able to afford that treatment and might not be treated.  So, by having a dual model and being flexible, we are able to service a greater group of patients, a greater proportion of society.

To give you an example, GP’s will often refer to Vita Health Care and say, “could this person be bulk billed?” – we would do that.  So, that is the sort of flexibility that I think becomes important, but I think we can’t shy away from the fact that we are intricately associated with the economic system and we’ve got to understand private health insurance, we’ve got to understand KPI driven funding, we’ve got to understand the impact of short term decision making on longer-term economics of the society.

James – Yes, and understanding our place within a very complex interdisciplinary system.

Sanil – I’m a big fan of Nassim Taleb, the author, and in his book, he talks about “skin in the game”.  People tend to make decisions very differently when they have actually got skin in the game, which is where they are exposed to the risks.

For example, with the clinic here, we have got to think about software – so we would invest in software, which is expensive so that it makes patient care better, GP communication better and at the same time, productivity within the clinic better.  These are some of the decisions that might not be considered in the public system and we would just go with whatever the overarching bureaucracy decides to do.

SKIN IN THE GAME

James – Nothing ventured nothing gained or at least, if you want to make an omelette, you’ve got to break some eggs. 

Sanil – That’s right.  So, skin in the game is I think a really crucial concept in making any decisions because when we think about investments that come from the government, there is a great saying –

Bureaucracy is nothing but a construction of a framework that creates the maximum distance between the decision maker and the person feeling the consequences of the decision.

If both those parties are the same or are both feeling the impacts, better decisions will be made.

PSYCHIATRIST IN PRIVATE PRACTICE - INTERACTION WITH SOCIO-POLITICAL VARIABLES

Yes, because when you are in private practice, there is only you between the patient and the company or the institution.

Sanil – That’s right. Often when newer Consultants get into private practice there is a hesitation in terms of charging, for example, and that’s because of the way we’ve been taught to think.  In an ideal world it would be perfect to not charge patients and at the same time, earn a good wage and put food on the table, all of those things.

Take, for example, Vita Health Care – one of the factors that would allow us to do that significantly would be if real estate costs were lower, therefore the lease would be low.  So, you can see how a completely different variable such as real estate costs has an impact.  If the real estate costs were 50% lower, then patients would be bulk billed and this is completely linked to real estate, which is absolutely nothing to do with medicine.

So, it just gives you an idea about how intricately we are linked with socio-political variables as well; interest rates with banks is another example.  I think if we are taught these things right from the beginning it would really help.

TALKING EXAMS- APPROACHING THE CRITICAL ESSAY FOR RANZCP EXAM

James – So, we play varied and flexible roles in varied and complicated systems.  It makes for a really interesting and stimulating career. 

So, Sanil, I guess in coming to the end of things, I haven’t been asking this question in some of the other podcasts, but I think for you, in particular, you’re very well suited to think about this.  With the original idea being aimed at trainees preparing for exams, I wonder if you have any kind of thoughts on how people might prepare – not in terms of the technical, practical aspects of writing the essay – but in thinking about these kinds of concepts and having these discussions around issues on the fringes of psychiatry and mental health.  What kind of things to read, what kind of things to watch, what kind of things to listen to, or what kind of concepts might be helpful for people to get involved in?

 

Sanil – Critical essay is, of course, a stumbling block for many; language is one reason but second is the breadth of thought.  The thing about the essay is that it is not something that one just starts preparing three months in advance and suddenly can create an essay.  The reason is, one can write an essay but the thoughts and the connections that need to be made have to bake for a very, very long time.  Therefore, the real preparation for essay probably starts when you enter psychiatry.

There is so much work, unknowingly, that can be done right when one starts psychiatry, to be able to keep your ear to the ground at all times; because ultimately it is nothing but a compilation of collective wisdom.  That’s what an essay really is.  What we want to do is to be able to compile the wisdom from a range of fields and of course, stick to the marking scheme where they talk about broader models of health and illness, cultural sensitivity, the history, ethical aspects, your clinical experience and recovery.  They have given you the anchors in the marking scheme, so to be able to think about, what does psychiatry’s history look like, nowadays, that’s where internet can be used to just Google, pick an article that one likes, or view a video and one gets a good feel for the story about the history.

In terms of broader models of health and illness,  there are some textbooks that one can start reading, even the Oxford Handbook of Medicine in the initial pages there is an outline of the mind-body dichotomy. How do psychiatry and neurology separate, where does psychiatry sit in the broader landscape, how psychiatry is now coming closer to other specialities such as neurology – this field of neuroimmunology, psychoneuroendocrinology, psycho-oncology.

There are some really nice articles in journals, so it requires some searching, but at the same time, for example in Australia, just listening to Q&A on the ABC every Monday for a big chunk of the year and just thinking about, how does particular policy or comment link to psychiatry?  Training one’s brain constantly to be able to make connections to psychiatry helps immensely because after a while, it just becomes second nature.  What one is doing is strengthening that implicit memory – the procedural memory – to think in that way and then strengthen the connection of the frontal lobe, the working memory side of things.  Listening to debates in a grand round is another way.  Another example, as you mentioned, is podcasts.

There is so much work that can be done in the year leading up to the essay, without necessarily sitting down to do it.

PSYCHIATRY AT THE INTERSECTION OF MULTIPLE DISCIPLINES

James – That’s the thing, you have to immerse yourself, sensitise yourself, put yourself out there and immerse yourself in ideas related to it.  Every news article you read, or every conversation piece you read or listen to, you have to think, how do I distil my thinking on this, how would I encapsulate this big concept in one sentence? 

Sanil – Absolutely, and psychiatry is perfectly placed, it is one of those fields that intersects, as we said earlier, with so many different disciplines, which is what makes it so fascinating and I think that’s really what needs to be communicated in the essay as well.  Your ability to show that psychiatry intersects with all of these different fields; one needs to create that sort of feeling in the examiner where they think, “that’s interesting, those connections that the person has made are really fascinating”.

I tend to mark essays as part of the course and what I see is that often generic statements are used and I have to look back at the original quote and ask how it connects to this.  Candidates have read history, they’ve read broader models of health and illness, they’ve read culture but they’re not making the connections with the original quote.  I think that is the really important thing; it is the connections, at the end of the day, that really highlights the breadth of thinking but that takes time to develop.  So, it is really crucial that candidates start right from the beginning.

Coming to disciplines, just yesterday I read an article that was fascinating which was about the big stock market drop recently and how Australia and the U.S. are going into recession in 2019/2020; but the article was written by a Psychiatrist, Brett Steenbarger, who is an Associate Professor at Suny and interestingly, he works as a Performance Coach for hedge funds.

So, reading that article and then looking at the author, as a Psychiatrist, just shows you how psychiatry can intersect with a completely different field that we have not thought about.  To be able to utilise a concept like that – the role of a Psychiatrist as a Performance Coach, whether that is sports or whether it is finance – it just shows that ultimately we are able to think about those variables that I mentioned and to be able to make those connections and create a framework for a range of people to achieve their potential.  That’s our role.  That’s how I see our role as a Psychiatrist at the end of the day.

I know I digress a little bit but I think that if everyone entering psychiatry thinks about themselves as being able to touch a wider range of disciplines, the essay becomes a normal outcome anyway if they start thinking right from the beginning.  When we talk to Psychiatrists, almost every Psychiatrist that I have met has a different interest, there is something else that they are really interested in and psychiatry is a field that allows one to explore that.  It is one of the fields where you can go on a sabbatical for a year and you are actually valued a lot more when you come back because that sabbatical has given you the time to think.  That is our most prized possession, our ability to think in many different ways.

COLLECTIVE WISDOM

James – To develop wisdom and then use language as the tool because that is the only tool we have. 

Sanil – I think that fits in perfectly with everything that you have just said, develop the collective wisdom and then become an educator.  That’s what we are doing.

James – Well, it is nice to come full circle then.  With that, thank you very much, Sanil, for coming on the show; I really appreciate your time and I appreciate Psych Scene’s support for the show.