Abstract
Objectives
Professional isolation and limited opportunities for multidisciplinary collaborations are well-recognised challenges for psychiatrists in private practice. This narrative paper describes the development of a private practice group to assist first responders (FRs) and military patients located in Adelaide, South Australia. The aims included both peer review, and interdisciplinary communication and collaboration. Relevant personnel in the ambulance, police and fire services, military and veterans’ groups, and the compensation system, participated in monthly meetings. Lack of timely access to psychiatric care for FR and military patients was identified as a problem and an expedited referral service was established.
Conclusions
The Closing the Gap Group was established in 2017. The terminology refers to the gap between treating psychiatrists and the complex organisations that manage the workplace context for FR/military patients. This initiative provides a template for private practice innovations to improve psychiatrists’ skills and knowledge, along with better engagement and understanding between private psychiatrists and relevant community organisations.
Almost half (40–50%) of RANZCP members work in private practice and treat some 50–60% of patients receiving specialist mental health services. 1 Professional isolation and lack of opportunities for peer interaction and multidisciplinary collaboration are recognised challenges for private practitioners. There is little published research, or descriptions of novel strategies, addressing these challenges. 2 We describe a successful private practice innovation, which improves care for a high priority patient group, increases engagement with a range of key individuals and organisations, and provides education and upskilling for private psychiatrists.
Many first responder (FR) and military patients are treated by private psychiatrists. Each patient is embedded within a complex organisation, with unique approaches to workplace injuries, support for mentally ill workers, compensation and rehabilitation. The individual nature of private psychiatry means that in response to the needs of specific patients, each practitioner builds up their own knowledge base relevant to each organisation.
Bushfires, the COVID-19 pandemic and the Senate inquiry into veteran suicides have highlighted the roles of frontline personnel in emergencies, disasters and combat. One in three FR personnel reports high levels of psychological distress despite careful selection and robust training.3,4 The Australian Defense Force (ADF) Mental Health and Wellbeing Study, with a 52.5% response rate (n = 26,281) of all employed ADF personnel, found 22% of respondents met criteria for a mental disorder over the preceding 12 months. 5
Alongside this, the shift work of FR occupations disrupts circadian rhythms, impacting on mood and safety outcomes. The risk of making a compensation claim is three times greater among FR than other occupations. Entering the compensation environment carries psychological risks.3,6,7 Most negative health effects occur in claimants who have a poor understanding of the claims process. 7 The psychological injuries suffered by FR and defence personnel are incurred while serving the community and care for these groups should be timely and comprehensive. Often, as demonstrated by veteran suicide rates, this does not occur. 8
Exposure to disasters, emergencies and combat can cause post-traumatic stress disorder (PTSD). In high trauma environments, occupation-specific factors complicate standard psychiatric treatment. Other complicating factors may include lack of a safe working environment, risks of re-exposure, difficulties in team environments, working within a chain of command and the complexities of a compensation claim.
There can be ‘gaps’ in private psychiatric management of FR and military patients. The different social or occupational environments that patients operate in can be obscure to private psychiatrists. Military environments provide another layer of complexity as the relevance and importance of psychiatric diagnoses may vary based on the lens of the observer, be it military chain of command, healthcare provider, insurance provider or government department such as Department of Veteran’s Affairs. Patients may be concerned that psychiatric diagnosis will prevent them progressing in their chosen career.
There can be problems with timely access to acute care in the private sector. FR and military patients may experience a severe traumatic event resulting in an acute stress reaction, often against a background of prolonged, repeated trauma and a demanding work environment, but in SA, there is no systematic means of obtaining timely access to a private psychiatrist.
We describe the Closing the Gap (CTG) Group, established by a group of private psychiatrists, to improve access and quality of care for FR and military patients in Adelaide, SA. The name refers to the gaps described above, and there is no relationship to the Australian Government agreement on CTG in Indigenous health outcomes.
Methods
A group of private psychiatrists with extensive experience treating trauma-related conditions formed a peer review group which actively reached out to commanders in the ambulance, police and fire services, and military and veterans’ groups. Members of the compensation system that often surrounded these patients were also invited, including insurers and representatives of plaintiff law firms. The group included a psychiatry trainee (AJ) with an interest in military psychiatry (Table 1).
Meetings were held monthly, began with a shared meal, and lasted for 2 hours. The space chosen was compact, to facilitate a kitchen table atmosphere where dialogue could be relatively intimate, frank and sometimes blunt. All members of the group were aware of the need for confidentiality.
Meetings alternated between case presentations to which referral sources (e.g. military base doctors and psychologists responsible for ambulance and emergency services) were invited, and discussion forums. An invited speaker would give a 15–30 min presentation and then act as a resource person for subsequent discussion.
Description of aims and membership of closing the gap group.
Results
CTG group meetings
Examples of topics discussed.
The willingness of some individuals in these organisations to continue pursuing traumatic experiences was notable. This was a combination of denial of the psychological effects of work, accepting those same psychological effects in order to continue making a difference, and the fact that this dangerous but exciting work was ego-syntonic.
There were some reassuring findings. A representative of a veteran’s organisation described a dynamic within a group of military patients; in that, there was a tendency to encourage competition in the recovery process but simultaneously, these same individuals performed the role of peer mentors by recognising and actively assisting those falling behind. This dynamic was attributed to the esprit de corps instilled from military training. The group also discussed a Canadian advocacy model that emphasised training non-government affiliated individuals to act as ‘middlemen’ between claimants and the relevant healthcare or compensation provider.
Expedited referrals to private psychiatrists
Referrals April 2017–April 2021.
Discussion
The CTG group aimed to bridge the ‘gap’ between treating psychiatrists and the social/occupational environment of military and FR patients. This was achieved by bringing together the relevant persons and their unique skillsets and knowledge, in a collegial setting. The original inspiration for the group came from two sources: the Chinese book the I Ching, the hexagram of change states ‘before beginning change go to the people three times’ 9 and the Dutch community nursing organisation Buurtzorg, which focuses on the development of community networks, and semi-autonomous and innovative locally based teams.10
The CTG group provides a template for private psychiatrists to develop a special interest group, encouraging sharing of information and skills, and enabling professional networks to be formed. Looi and Atchison 2 described the need to tailor professional development for private practice, noting that appropriate and expanded peer review processes may assist in reducing professional isolation. The CTG group is an example of an innovative peer review group, with additional benefits in linking with other professionals, working together to improve patient outcomes. The CTG group streamlined delivery of multidisciplinary health care for psychological injury, expediting the claims/referral process, limiting the burden of psychiatric illness and enhancing knowledge of those involved.
The organisations engaged with the CTG group expressed considerable gratitude for the group’s existence, sought advice frequently, and were keen to return to meetings to talk about progress. There was particularly high regard for the timely fashion in which urgent problems could be responded to, including FR from the Kangaroo Island bushfires.
Relationships between these organisations and CTG members continued to build and increasingly the function was that of a network rather than a single point of triage. A particular strength was sharing of knowledge and experience by senior clinicians for situations which by their complexity were outside the available expert guidelines.
There was ongoing engagement between private psychiatrists and the trainee member of the group. There are no private psychiatry placements in Adelaide so this was a unique opportunity. Although many trainees will work in private practice, there are few avenues for them to interact with private psychiatrists during their training.
In the public sector, such meetings would generally occur during the work day. The CTG meetings took place one evening/month, and were recorded as an RANZCP peer review group, enabling participants to meet their CPD obligations.
Aims of the military and veterans’ mental health network.
A private practice group which extends into collaboration with other organisations and provides expedited referrals has risks and limitations. Such initiatives depend on the enthusiasm and organisational capacity of a small number of people, who can become over-committed. There is a risk of over-promising to other organisations, resulting in disappointment and damage to relationships. There may be too many referrals, overwhelming the capacity of the private psychiatrists involved.
Conclusions
The CTG provides a novel template to extend private psychiatry into a collaborative model, working with a high priority group of patients who are premorbidly resilient and high functioning. The opportunity to engage with FR organisations and the military by meeting with highly skilled members of these organisations provided a learning and networking opportunity for the private psychiatrists involved. This model can be extended to other private practice scenarios, with special groups of patients, for example, professional groups such as doctors and teachers, or patients with special needs due to specific disabilities.
Footnotes
Acknowledgements
We thank the members of the group and many organisations and individuals who contributed, and Ms Carol Turnbull, CEO, The Adelaide Clinic, for her support of the group.
Disclosure
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
