Careers

C1MJA 199 (8) · 21 October 2013

CareersMJA

Editor: Cate Swannell • cswannell@mja.com.au • (02) 9562 6666

continued on page C2

survive but see an increasingly troubled population”, Dr Kenneth Nunn, a senior child psychiatrist at the Children’s Hospital at Westmead, Sydney, who has worked closely with those at Sherwood House, tells the MJA.

Dr Nunn is the chair of the NSW Branch of the Royal Australian and New Zealand College of Psychiatry’s (RANZCP) Faculty of Child and Adolescent Psychiatry and says the crisis has been brought about by a combination of lack of planning, ongoing workforce shortages and poor resource allocation.

The system is at the point of being overwhelmed, he says, and in August outlined the problems facing child and adolescent psychiatry in NSW to the Minister for Health Jillian Skinner and the NSW Mental Health Commissioner John Feneley. The Minister is yet to reply.

While there is gross underservicing in NSW, and similarly in Victoria, Dr Nunn’s national counterpart at the RANZCP, Dr Nick Kowalenko, says that in the Northern Territory, Western Australia and Queensland the shortage is even more acute.

In late 2012, Health Workforce Australia (HWA) identifi ed psychiatry in general as a red fl ag area for potential workforce shortages in its forecasts up until 2025.

Child and adolescent psychiatry wasn’t mentioned as a subspecialty within the report but such specialists make up about 10% of the psychiatric workforce.

According to HWA fi gures, that workforce had dropped from 2981 in 2009 to 2586 in 2011.

A 2010 RANZCP planning report for infant, child and adolescent mental health explicitly identifi ed recruitment and workforce shortages as major problems for the fi eld.

The consequences of the shortage have been hinted at in the only

In this section

C1FEATURE

Crying shame

C2Boost for medical education

C4Heart and soul

“There is no distinction between nature and nurture. It’s an intricate web

’’ Dr Magella Lajoie

In south-west Sydney, a specially designed house is home to six young people. The boys and girls aren’t

family, except in the sense of a shared history of complex and enduring abuse and oblivion-seeking drug-taking, self-harm and often prostitution. They are as young as 12 years old.

Sherwood House is surrounded by garden, but is a secure facility, meaning none of the six can leave of their own free will. But Sherwood isn’t a juvenile justice facility.

It is a therapeutic care centre belonging to the New South Wales Department of Family and Community Services in partnership with the federal Department of Health, and is one of a small but growing collection of similar secure homes around the country.

These “homes” provide care and treatment for children and young people caught at the pointy end of today’s severely overstretched youth mental health services.

Increasingly, the evidence shows that such young victims of abuse may be helped and kept out of such facilities by the earliest possible intervention, with a combination of primary care and psychiatric treatment

Crying shame

for post-traumatic stress disorder (PTSD) from as young as 3 years old.

But while child and adolescent psychiatrists (CAPs) are now identifying the need, chronic workforce shortages in child psychiatry and inadequate resources appear to be getting in the way of effecting even the small differences that may be of great benefi t.

Those who have been working in the fi eld for many decades say that the situation is worse than ever before and is still deteriorating.

This is occurring at a time when, in NSW, there is now only one juvenile mental health bed per 500 severely and enduringly mentally ill young people.

And with roughly 10 000 babies being born in the state each year, there are as few as fi ve new graduates with training in advanced child and adolescent psychiatry entering the workforce.

It has compelled those working in the fi eld — not only in psychiatry, but also in primary care and allied health — to have powerful informal systems in place so as not to be overwhelmed by the community’s need.

“Child psychiatrists have erected large triage walls around them to

nn ssououththhtht w-wwesesttt SSSySydddndneyey aa spspececiiaiallllllyy ffoforr popostst t-traraumumatatiicic sstrtresess diso

A chronic shortage of child and adolescent psychiatrists is leaving vulnerable children and young people without necessary treatment

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Careers

C2 MJA 199 (8) · 21 October 2013

epidemiological study of child and adolescent mental health yet done, which was completed at the turn of the millennium.

It found that 14% of 6 to 16-year-olds had mental health problems but less than a quarter of those were receiving treatment.

The consequences can be severeEarlier this year in a submission to the NSW Supreme Court in support of Sherwood, Dr Nunn pointed to the example of the recently convicted murderer, Daniel Stani-Reginald, as a possible outcome of inadequate care.

Despite the self-evident traumatic experience of having had his father kill his mother, and subsequent social impairment and a clearly altered personal function, Stani-Reginald had not met the psychiatric criteria for illness or intervention at that time and intensive inpatient treatment had not been available during his critical teenage years.

“When you have a shortage like this, what happens is that child psychiatrists then only do the pointy end of the work, which means a lot of work that child psychiatrists are so good at doing, doesn’t actually happen”, Dr Magella Lajoie, director of training in child and adolescent psychiatry at the NSW Institute of Psychiatry, tells the MJA.

But Dr Lajoie is enthusiastic about the rewards for those working in the fi eld and says evidence of the need for and benefi ts of early intervention for children with mental health problems is rapidly building.

“The most exciting advances in psychiatry during the past decade have been in neuropsychiatry and the evidence of the effects of trauma”, she says.

“This means that for a lot of the illnesses now appearing in adolescents and adults there is much clearer evidence that they have a root in childhood or even the mother, before the child was born. It is negating the nurture versus nature argument. There is no distinction between nature and nurture. It’s an intricate web.”

The training process for psychiatry, including subspecialties such as child and adolescent psychiatry, was changed by the RANZCP this year so that the fellowship can now be achieved in 5 years, rather than the previous 6-year training requirement.

Drs Lajoie, Bowden, Kowalenko and Nunn hope that the shorter training period will encourage more medical graduates to consider specialising in the fi eld.

Australia is not alone in struggling with this problem. There are similar shortages of child and adolescent psychiatrists in much of the developed world.

Recent research in the United States and Europe suggests that introducing students and graduates to the subspecialty and its research and results is effective in building numbers, and also in building expertise in those working in related fi elds such as paediatrics.

The latter is particularly valuable at a time when

research by the Australian Paediatric Research Network shows that a signifi cant amount of paediatricians’ clinical time is now devoted to children with mental health and behavioural issues.

Dr Lajoie’s colleague at the Institute and former chair of the NSW Faculty, Dr Michael Bowden, says the challenges of the fi eld are also the sources of its greatest satisfaction.

“When you’re working with children, they’re always part of a larger system — not only the family, but the peer group, education and so on. You have to think about groups and interactions within groups, which makes it very complex”, he says.

“Those of us working in child psychiatry, we love that kind of complexity and that you do get to work in teams.”

To that end, the recent changes to Medicare, opening it to psychological and other allied health treatments, have also made it much easier to build teams to work with troubled young people in the private sector.

Looking ahead, Dr Kowalenko says that the need for psychiatric expertise in children is only likely to increase with what he predicts will be a second wave of intervention — following on from the work of Professor Patrick McGorry in the adolescent and young adult realm.

“There’s been an explosion in the recognition of child and adolescent mental health problems — part of that has been the recognition of youth problems. And the second wave of early intervention, which is going to be about younger kids, those under 8 years, hasn’t really even started yet.”

All the research is pointing to the importance of providing early and ongoing help for children subject to abuse and other forms of trauma in the hope of avoiding incarceration in facilities such as Sherwood.

“It’s only just beginning to be recognised that children who have been abused probably have PTSD and it needs to be specifi cally treated”, Dr Kowalenko says. “Once you leave it too long, you’re in this horrible situation where you create the fairly chronic problems.”

Dr Nunn is nearing retirement after a career that has included leading the Department of Child Psychiatry at both the Children’s Hospital at Westmead and St Thomas’s in London, as well as stints with Justice Health in NSW and as Professor of Psychiatry at the University of Newcastle.

He says that, ultimately, amid such limited resources, Sherwood becomes a place of real hope for kids who have lost everything.

“I cannot tell you the joy of seeing the kids in there. Can you believe that such lives could be rebuilt?”

Annabel McGilvray

Boost for medical education

A new $17 million education centre at Sydney Adventist Hospital (SAH) will be offi cially opened on Friday, 1 November.

The centre is home to the SAH Clinical School of the University of Sydney, and the Avondale College of Higher Education’s Faculty of Nursing and Health.

After the ground-breaking ceremony in June 2012, the centre’s completion marks the end of Stage 1 of what is expected to be a $181 million redevelopment at SAH, which will eventually include a purpose-built integrated cancer centre, a maternity and women’s health unit, and an additional 12 operating theatres and 200 patient beds.

The centre provides access to state-of-the-art purpose-designed technology, furniture and spaces to maximise collaborative and eff ective learning.

The centre includes the Charles Warman Auditoria and Foyer, Beverley Ellen Peters Clinical Skills laboratories, problem-based learning rooms, simulation centre, a library, and staff and student areas.

By 2016 it is expected that up to 40 doctors per year and over 120 nurses per year will be training in the new facility. With limited public sector placements for students, the centre will provide increased clinical training day opportunities.

By 2016 with greater capacity and student enrolment, it will be providing 21 420 medical student training days, 11 028 nursing student training days, and 2760 allied health professionals training days.

The redevelopment project is a joint venture project between the federal and New South Wales governments, University of Sydney and the Avondale College of Higher Education.

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Careers

C3MJA 199 (8) · 21 October 2013

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Careers

C4 MJA 199 (8) · 21 October 2013

When Professor Ian Haines cried on ABC current affairs show Four Corners on 26 August, it took him by surprise.1

“It caught me off guard”, Professor Haines, a medical oncologist at Cabrini Private Hospital in Melbourne, tells the MJA. “I’m not often brought to tears, but it doesn’t worry me that I was upset.

“Patients share so much with me. It’s such a privileged job I have. I get to know them so intimately and there’s a bond that forms. I love that about my job.”

The immediate trigger for Professor Haines’s tears was recalling the moment when he had to tell the teenage son of one of his patients that his mother’s cancer was incurable.

“That was a key point in his life. He’ll never forget that moment”, Professor Haines had told Four Corners, through his tears.

Looking back on it now, Professor Haines acknowledges that there was more behind his emotion than young Nathan’s situation.

“I remember being about that age — 15 or 16 — when [a relative] was diagnosed with aggressive ovarian cancer in her late 30s”, he says.

“In those days (the early 1970s), there was no treatment beyond surgery. I watched her over many months when she was in absolute agony. My mother would stay up all night for months looking after her.

“That affected me, no question.”Professor Haines took that experience

and turned it into a storied 30-year career in oncology, pain management and palliative care.

After graduating from the University of Melbourne in 1978, he completed a medical oncology fellowship at Alfred Hospital in 1984. He then became the fi rst Australian to be accepted into the clinical and research fellowship program at the prestigious Memorial Sloan-Kettering Cancer Centre in New York.

On his return to Australia in 1987, he set up the Melbourne Oncological Group, established and ran undergraduate teaching courses in palliative care at both the University of Melbourne and Monash University, and helped establish Cabrini’s own dedicated 24-hour domiciliary palliative care nursing service in 1999.

He ran a busy practice in Dandenong — “I like being able to give people in poorer areas the opportunity to access quality health care” — and worked long, gruelling hours week after week.

It all came to a shuddering halt on his 57th birthday, late in November 2011, when he suffered a cardiac arrest in the Cabrini car park. His life was saved by a passing orderly who performed CPR on him for 7 minutes.2

“You don’t drop dead for no reason”, Professor Haines says.

“My heart was normal, but I was trying to do too much. I had always thought that I could do twice as much as anyone else, but I was exhausted by the end of the week.

“I had to take it on board, honour the event. So I made changes to the way I practise. I gave up a lot of my work out at Dandenong, cut back on the number of patients I see each week.

“My heart attack was not as profound an experience for me as it was for my family. For me, I was asleep and then I woke up”, he says.

“I was incredibly lucky and I do have some survivor guilt about that. Knowing what my patients go through every day — what right do I have to be alive and well while they are going through so much?”

Professor Haines has two main aims in doing interviews like this one and the Four Corners story.

“I saw it as an opportunity to show patients that doctors do care”, he says. “And it is vitally important that people are given accurate information.

“Cancer is a disease of ageing. If we

“Knowing what my patients go through every day — what right do I have to be alive and well while they are going through so much?

’’

Heart and soul

live long enough we’re all going to get either dementia or cancer and neither of them are good.

“We have a distorted view of cancer because when young people get it — people like Kylie Minogue, Belinda Emmett, Jane McGrath — there is a disproportionate amount of publicity”, he says. “But the message gets lost along the way and we don’t get accurate information.

“Everyone hopes they are the exception and hope is such an important thing, but we have to be responsible enough not to give false hope.”

The future of health care, Professor Haines says, is not in hospitals but in community care.

“We need to trust the public to help us work out the priorities”, he says. “The community is very intelligent when we give them the correct information.”

With the baby boomers inching towards old age, advance care plans and end-of-life conversations are becoming crucial, Professor Haines believes.

“The big debate in our lifetime, among those of us who watched our parents die without advance care plans is: ‘Where will we be as our lives end?’ I don’t know where I will be.

“We have to take part in this debate.”Professor Haines may have cut

down on the number of patients he sees but there is no diminution in his commitment.

“I don’t think I’m burned out”, he says. “I feel energised, full of satisfaction.”

His wife, Wendy, and his four grown children, keep him grounded.

“I’m full of passion and ideas and Wendy is the perfect balance to that. She keeps my feet on the ground.”

1. Four Corners 2013; Buying time. http://www.abc.net.au/4corners/stories/2013/08/26/3831617.htm

2. Seven News 2011; Oncologist Professor Ian Haines survives cardiac arrest. http://www.youtube.com/watch?v=HhwjNAbG0CY

Cate Swannell

Professor Ian Haines is a medical oncologist who is unafraid to wear his heart on his sleeve if it helps his patients feel supported through their cancer treatment

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Careers

C5MJA 199 (8) · 21 October 2013

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Careers

C6 MJA 199 (8) · 21 October 2013

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Careers

C7 MJA 199 (8) · 21 October 2013

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Careers

C8 MJA 199 (8) · 21 October 2013

Overseas Appointments

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■ Consultant Psychiatrist in Child and Adolescent Mental Health Service – immediate start.

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Full Time or 8PAs Ref: 427-MD8046MAre you interested in coming to work in the UK for a year or longer? We are a dynamic and well respected team of 11 Geriatricians here in the beautiful Georgian city of Bath, a UNESCO World Heritage city, and we would like to invite you to join our expanding department.

We have developed a new post based in our acute hospital Trust and with our community partners. This is a fl exible post, enabling a job designed to suit the ideal candidate. This post offers opportunities in acute medical assessment, community services, comprehensive geriatric care, rehabilitation and, if interested, you could get involved in research. Within the department our current research interests include dementia care, osteoporosis, end of life care and movement disorders with links to both the Universities of Bath and nearby Bristol.

This new post offers a great balance between acute and intermediate care work. It was developed in conjunction with Sirona, a community interest company (or social enterprise), which manages community hospitals and services in the Bath and North East Somerset area. The post rotates with a current consultant between acute work at RUH and community work at Paulton and St Martin’s hospitals. The acute ward (one of 5 older people’s wards) is fully staffed with 3 junior doctors, a registrar and a team of therapists – you would be responsible for 14-20 beds and would take part in an on call rota, for geriatric medicine only, of 1 in 7.5 including weekend post take ward rounds. The job would also include outpatient work at the RUH and in the community. In the community you would be supporting GPs, the community teams and community hospital beds in conjunction with a specialty doctor and nurse practitioner.

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For a discussion relating to research please contact Dr Celia Gregson, Consultant Senior Lecturer at the University of Bristol (Tel. 01225 821267).

Closing date: 4 November 2013.

To view the job description and to apply online, please visit www.ruh.nhs.uk

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