Abstract
DEAR SIR,
A discussion paper seeking to promote debate about the development of an Advanced Training Program in Adult Psychiatry (ATPAP) was published in an earlier issue of Australasian Psychiatry. 1 It was proposed that ATPAP should encompass the diversity of practice within Adult Psychiatry and provide a core of advanced knowledge, skills and attitudes that will equip psychiatrists to meet the challenges of population and service system needs. It was argued that this would reduce dissonance between expectations developed in training and the reality of practice. The lack of any specific representative group within the Fellowship driving the changes required was identified as an obstacle to this process. A fax-back form was included in the article to gauge the opinions of the Fellows about the proposal. I write to inform readers of the results of this survey.
Twenty-five responses were received, seven from trainees. Fellows who responded had an average of eighteen years post-fellowship experience. Private practitioners were slightly under-represented, being 36% of survey respondents but 57% of College Fellows. 2 Public practitioners were 44% of survey respondents and represent 38% of College Fellows. 2 The main subspecialty area represented was general/ adult, comprising 52% of survey respondents.
There was support for the statements ‘there is a need for an ATPAP’ and ‘if an ATPAP had been and/or could be available to me I would have/will seriously consider it as a career option’ although a significant minority of respondents strongly disagreed. Respondents identifying their main area of practice as general/adult were more supportive.
There was strong and unambiguous support for the idea that an ‘ATPAP should reflect diversity of practice within adult psychiatry’. This was matched by strong support for the statements ‘an ATPAP should adequately equip specialists in Adult Psychiatry to assess and manage patients with complex needs, ‘an ATPAP should adequately equip specialists in Adult Psychiatry to assume the roles of leader, manager and consultant’, and ‘an ATPAP should be available to all who are interested on an equitable basis’.
Views about the statement ‘an ATPAP should be founded on a population mental health model’ were more neutral.
Sixteen respondents made additional comments covering a range of themes. Three respondents were critical of the discussion paper and the concept of an ATPAP, questioning whether the area warranted status as a sub-specialty. One respondent felt that the aims of an ATPAP should be achievable in basic training. Other concerns were the difficulty attracting advanced trainees to an area not perceived to be a sub-specialty or to offer more training than service opportunities, that an ATPAP may create more hurdles in training, that an ATPAP may be divisive or exclusive, that a focus on population mental health may ‘detract energies from actually treating patients’, and that such a model is not relevant outside of the public setting. One respondent felt that the term ‘adult psychiatry’ lacked specificity and would lead to the area becoming a ‘dumping ground’ for patients not accepted by sub-specialties. Survey respondents also advocated for the inclusion of specific subspecialty areas within the curriculum. Addiction and forensic psychiatry were those nominated.
The low response rate (from a potential pool of 2500 Fellows and 850 trainees) was clearly disappointing. Several factors may have contributed. The fax-back form not being a loose leaf may have created an obstacle to its return. E-mail received after the due date referred to difficulties completing the form. A differently designed form may have improved the response rate. There may have been reservations about what could be seen as a political initiative arising from a particular geographical location. Apathy or a sense of powerlessness within the Fellowship may also have contributed to the disappointing result.
The survey is obviously not a representative sample of College Fellows and neither intended nor claims to accurately measure opinion about the issues raised. The discussion paper was intended to raise the issue of Advanced Training in Adult Psychiatry, promote debate and invite comment from Fellows and trainees. Those who have responded have self-selected, presumably on the basis of their interest in the issue.
The fear that the area will become a ‘dumping ground’ for problems not accepted by specialist services seems to underlie concerns about the name. In the United King-dom 3 the term ‘emergency and community psychiatry’ has been suggested. ‘Adult Psychiatry’ was chosen for the discussion paper for its simplicity and consistency with other developmentally defined subspecialties (child and adolescent, and old age). The semantics seem less important than clearly defining the boundaries of the concept.
The arguments that Adult Psychiatry warrants recognition as a subspecialty were advanced in the discussion paper. 1 Developments in national mental health policy mean that it is no longer sufficient to be a competent clinician; it is also necessary to be influential at a systems level. This requires special skills in communication, collaboration and health advocacy. The imperative to develop these skills is emphasized by criticisms of access to psychiatrists 2 and evidence about unmet need within the com-munity. 4 , 7 New funding models encouraging collaboration with primary care providers will promote the move away from a traditional specialist role towards more of a consultancy role. This will effect both private and public sectors.
The high level of disability and comorbidity identified within the National Survey of Mental Health and Wellbeing 4 , 7 and demand for effective and timely crisis interventions highlight the expertise in the management of complex and comorbid conditions and in the application of evidence based psychological and pharmacological interventions required by the specialist in Adult Psychiatry. Failure to address such population needs endangers the credibility of the profession.
Problems attracting and retaining trainees reflects competition from other areas perceived to offer more rewards. The absence of an attractive specialist training and career path in Adult Psychiatry that prepares trainees to practice as part of the broader system contributes to dissonance between the expectations developed in training and the reality of practice. Exposure of junior trainees to high-stimulus settings without adequate support leads to high rates of stress and burnout. A comprehensive and inclusive ATPAP may reduce this dissonance and attract more senior trainees to the area.
In line with RANZCP project team recommendations, 8 an ATPAP would incorporate developments in adult and medical education with a reduced number of assessment hurdles of better reliability and validity, providing a seamless transition into continuing medical education as part of a lifelong commitment to learning.
The low response rate suggests a significant level of apathy within the Fellowship and among trainees. Those who did respond were generally positive about the proposal. It is apparent that further consultation will be required to address a number of concerns if an ATPAP is developed. The lack of any representative group within the Fellowship driving the changes remains a problem. It is nevertheless possible that there is enough interest to form such a group.
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