Inside the Mind of Dual Psychiatrist and Pain Medicine Physician – Interview with Dr Khaldoon Alsaee

WHAT ATTRACTED YOU TO PSYCHIATRY?

Throughout university, I was very interested in Surgery & completed all my electives in Surgery.  Prior to my Psychiatry rotation in 5th year, I had a chance to read through the Psychiatry book & found it fascinating; very different to other medical specialties.  I felt it stood out from the rest because of the lack of clear-cut treatment algorithms.  I was also motivated by the fact that a lot of mentally ill patients are neglected within the health system & felt that I could make a difference.

 

WHAT ARE THE BIGGEST CHALLENGES THAT PSYCHIATRY FACES IN YOUR OPINION?

Of concern is the stagnation in new biological treatments that are available for common mental disorders.  I also find that Psychiatry still has a long way to go in selling its messages to the general public (and health care professionals) with regards to nosology, diagnostic formulation & treatment planning.  Additionally, and more importantly, I am concerned that major social issues & their impact on the individual & broader community are at times neglected.  It will take major political shifts for these issues to be dealt with to effect changes at a national level.

 

WHAT ATTRACTED YOU TO DOING A PAIN MEDICINE FELLOWSHIP?

To be honest, I was doing my advanced certificate in addictions & as a requirement was meant to rotate within a Pain Unit.  Before starting this rotation, I was asked by one of my mentors, Dr. John Reilly, the medical director whether I would be interested in pursuing a Pain Fellowship.  At the time, I didn’t even know it existed & after a few online searches, I enrolled shortly after & started the journey! 

What I liked was that it was a niche area.  In fact, there are less than 500 pain specialists in Australia & New Zealand & even less of whom have a background in Psychiatry.  I was also motivated due to the co-existence of addictive disorders & chronic pain along with other psychiatric co-morbidities.  Another area of appeal was returning to the unfortunately neglected aspect of physical examinations in Psychiatry.  It was truly a humbling experience. 

 

CAN YOU GIVE READERS A BIT OF AN UNDERSTANDING ABOUT THE PROCESS OF BECOMING A PAIN MEDICINE SPECIALIST AFTER DOING PSYCHIATRY?

To become a Pain Specialist, a doctor would have to obtain a Fellowship of the Faculty of Pain Medicine, from the Australia & New Zealand College of Anaesthetists (FFPMANZCA).  Basically,  it is an add-on fellowship.  Pain medicine includes three types of pain: acute pain, cancer pain & chronic pain. 

The process would begin by having completed all examinations through the Royal Australian & New Zealand College of Psychiatrists & applying to the Faculty of Pain Medicine to commence training.  There is an entrance exam that needs to be passed to commence training.  Training lasts two years long & is composed of a core training year & an additional year which is a practice development stage.  During the two years, the trainee would have to pass the two long case exams (just like the old OCIs), a 5000-word case report, and an exit examination (written & OSCE).

 

ANY SPECIAL TIPS FOR GETTING THROUGH THIS PROCESS?

Essentially my main tip to all trainees is to be ready.  It’s a humbling process going from almost being a qualified specialist to being a 1st-year trainee.  Learning how to do a full physical examination is important along with a pain oriented physical examination. 

The other major tip is to read & study from the curriculum.  It is comprehensive & extremely well written.  The last tip is to trust in your skills as a Psychiatrist!  You have a unique set of skills as a Psychiatrist which will naturally be useful in Pain Medicine.  I have to admit, half of my exit exam was Psychiatry which worked well in my favour. 

 

CAN YOU GIVE US ONE EXAMPLE -I'M SURE THERE ARE MANY-OF A CASE WHERE YOUR EXPERIENCE AS A DUAL ACCREDITED SPECIALIST ASSISTED IN IMPROVING THE PATIENT OUTCOME?

One case that stands out is that of a woman in her 40s who was overweight & suffered chronic back pain.  She was prescribed high opioid doses yet remained in significant pain as an inpatient after developing an infection.  As a dual specialist, especially with skills in Addiction Psychiatry, it was clear that she was injecting opioids & unfortunately developed Hepatitis C.  She was depressed & had a background of Cluster B traits. 

The biggest asset was the ability to explain her predicament clearly, including her MRI of the lumbosacral spine, and provide as much psychoeducation (including family psychoeducation) as possible about her condition, her personality, her mental health & her addictive disorder – essentially working through a diagnostic formulation with her.  She invariably ended up on opioid substitution under my care and I could use my skills to treat the variety of conditions she presented with. 

 

YOU HAVE BEEN IN PSYCHIATRIC PRACTICE FOR MANY YEARS NOW; WHICH CASE HAS HAD THE GREATEST IMPACT ON YOU AND WHAT HAVE YOUR LEARNT?

Every case is unique & has taught me a lesson or two.  One that stands out is a female patient that was bound to a wheelchair after having a hip fracture & needing a shoulder reconstruction.  She was physically incapacitated & in excruciating pain.  After a thorough assessment, it was very clear that she had a severe depressive episode. 

We learn a lot in psychiatry that patients can somatize, but with antidepressant therapy, this patient improved significantly in both pain scores and affect.  It was so dramatic that I finally realised the significant impact the brain can have on the rest of the body.  The brain or “supra-spinal area” is of significant interest in pain medicine & has significant overlap with psychiatric disorders. 

 

WHICH PERSON DO YOU ADMIRE THE MOST PROFESSIONALLY AND WHY?

I have had quite a few mentors throughout my career of whom I admire.  One that stands out is Dr. Jason Lee, currently Clinical Director of Rural, Remote & Indigenous Psychiatry at the Townsville Hospital & Health Service, and current RANZCP Aboriginal and Torres Strait Island Mental Health Committee Chair. 

I was lucky to have worked under his supervision for one and half years as a registrar, and he remains a good friend.  Essentially, he embodies the complete Psychiatrist. 

We learn a lot in both Psychiatry & Pain Medicine about our roles through the CanMEDS framework (Medical Expert, Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional).  Dr. Lee has always excelled in all these roles throughout the time he mentored me; was and remains loved by all his patients, colleagues and students and continues to practice bio-psycho-socio-culturally on a day to day basis. 

I can say that he always challenged me, and despite my frustrations with his approach, it has made me a better Psychiatrist and person. 

 

WHAT ARE YOU READING AT THE MOMENT?

I’m currently reading a book by Amin Maalouf; it’s called “On Identity.”  It essentially goes through a philosophical journey about identity using anecdotes from his life.  Some of the stories & examples resonate with me being from a similar background to the author.

 

HOW DO YOU SEE PSYCHIATRY DEVELOP IN THE NEXT 10 YEARS?

I think there will be more and more personalised treatments for individuals based on the hard work some of our colleagues are undertaking in the field of pharmacogenetics and pharmacogenomics.  What I would like to see though are doctors that are more psychiatrically oriented.  I think that Psychiatry has a lot to offer doctors at different stages of development and this would, in turn, help them be more mindful clinicians in whatever practice they choose. 

 

ANY FINAL WORDS OF WISDOM FOR READERS OF THE HUB?

Thanks, Sanil, I’m still very young in my career & feel wisdom has yet to come.  What I would share is that with my experience in a second speciality, I have found that my Psychiatric training has focused far too much on the cognitive aspect of assessment & management. 

Pain Medicine has taught me that the behavioural aspect, essentially the way a person functions is of equal, or more importance than thoughts.  It became very clear that if the only focus of treatment in Pain Medicine was pain relief or analgesia, the outcomes were poor & that a focus on function was essential overall. 

I would encourage all my colleagues, especially our new trainees to help their patients set realistic & achievable goals & work to achieving them despite the presence of a mental disorder. 

I would also like to mention that after going through the process of obtaining a Pain Fellowship, I found that interacting with colleagues of different specialities (Anaesthetics, Rehabilitation Medicine, Occupational Medicine, Gynaecology) under one banner was one of the richest experiences in my training and would encourage others to seek common ground with doctors from other specialities rather than silo themselves away.

Thank You Khal, It’s been a pleasure!