Transitioning to consultancy: From caterpillar to butterfly!

There is growing concern that the quality and sophistication of public psychiatric care is deteriorating. This is especially the case in Australia as compared to New Zealand where there is minimal private practice. However, in both countries and probably worldwide, there is diminishing interest in psychiatry with fewer trainees pursuing higher professional training. The two phenomena may be linked, and these trends have given rise to dramatic descriptions of public psychiatry as undergoing a ‘slow death’ (Aubusson, 2019). What are the reasons for this and why are more psychiatrists shifting into private practice, if this is indeed the case? Is it because of being disillusioned by their early experiences in the public sector? Here, we briefly review some of the possible reasons that may be contributing to this seeming exodus by considering the ‘transition to consultancy’ – a time of metamorphosis. Among the many anxieties that senior trainees face, the process of assuming consultant responsibilities is critical, and it is the factors associated with this transition, which influence and shape early careers, that we have focused on in this brief Debate.

Sticking with what you know?

Familiarity garnered through a typical training pathway may explain why continuation in the public sector post fellowship is a logical choice for many senior trainees. A greater sense of connection with colleagues, other medical professionals and allied health staff can provide a much valued (and much needed) ‘safety net’ of peer support. But with the rapid loss of senior psychiatrists from the public system, this may not be the drawcard it once was. There are now pockets of group private psychiatry practice where the level of senior support, for example, through ready access to sub-speciality second opinions, outstrips what is available in public sector, although arguably the nature of this peer support is likely to differ from traditional mentorship.

Furthermore, limited access to allied health services such as occupational therapy and clinical psychology detracts from the notion of multidisciplinary support in public psychiatry. In practice, such services may be more readily accessible in a private capacity – provided they are within financial reach or covered by a health fund.

Maintaining our integrity

Most psychiatrists take pride in their profession; however, current workforce issues hint at a deeper problem with the appeal of psychiatry among the general medical community and an erosion of respect (Rey et al., 2004). For some early career psychiatrists, the opportunity to protect and enhance the integrity of psychiatry may spur them to take on public positions in general hospitals. But with the gradual separation of ‘mental health’ from other areas of medicine and healthcare in general, collegiality with medical peers seems to be on the decline. At the same time, among the medical community, stigmatisation of the psychiatric profession itself seems to be on the rise, as psychiatrists are seen as the face and cause of an overstretched mental health service, constrained by the limitations of under-resourcing (Looi and Maguire, 2019). In practice, dealing with ostracisation, poor morale, a sense of underappreciation and workforce shortages may simply outweigh any potential benefits of public psychiatry for those in the early stages of their career. Solo private practice allows psychiatrists to operate with a degree of independence and autonomy, providing some distance from these public service workplace culture issues.

‘De-specialisation’

While multidisciplinary approaches to mental illness form the foundation of modern psychiatric practice, the proliferation of the notion of ‘mental health’ has contributed to other professions assuming responsibility for areas traditionally considered within the remit of psychiatry. In turn, there is a perception that psychiatry has become increasingly narrow in its focus with a skillset limited to either biological treatment or psychotherapy that is regarded as akin to non-specific psychological support. The presence of psychiatry in areas such as leadership and management, community advocacy and policy development seem to be diminishing. Increasingly, it seems the care of complex mental illness is being coordinated or directed by those without psychiatric training. For enthusiastic early career psychiatrists, a lack of recognition of highly specialised expertise in diagnosis and management can be particularly disheartening, especially after years of intensive and demanding training.

Despite this, psychiatrists continue to find themselves carrying the majority of clinical responsibility (particularly with regard to risk management), but this is now in the absence of the authority to instruct decision-making. For public psychiatrists particularly, a high level of clinical complexity must be managed (often in an under-resourced environment), but medical decision-making is increasingly being driven or influenced by non-medical management systems, leading to a sense of low autonomy and high responsibility – a particularly vulnerable position for those early in their career. Furthermore, despite psychiatrists continuing to bear clinical responsibility, their influence over policy and management dwindles, meaning less of an ability to shape future service design. This does not equate to less administrative responsibility though, as non-clinical demands, such as mandatory training, continue to grow. This means fewer hours for clinical practice, leading to personal dissatisfaction with the quality and standard of care provided (Looi and Maguire, 2019).

The causes for this shift are likely multifactorial, and beyond the scope of this article, but psychiatry itself must reflect on its own role in this development. Does the profession self-select those who shy away from conflict, or has the emphasis on rapport and engagement diminished our capacity to assert our proficiency and competence? Has the loss of senior psychiatrists from the public sector meant that those in training and early in their career lack role models to aid in the development of their leadership and management skills? It is critical that we reflect on these cultural factors, as this process of ‘de-specialising’ has contributed to a loss of the profession’s identity and disillusionment among its practitioners. This is particularly challenging for those early in their career as they work towards developing confidence in their new professional persona.

A changing focus

With a changing perception that psychiatrists are limited in their scope of practice to administration of biological treatments and clinical risk management, opportunities in areas such as academia become less of a priority (Henderson et al., 2014). Typically, public services have had a greater emphasis on such areas, and salaried hospital roles in particular have provided early career psychiatrists with opportunities to engage in scholarly pursuits. However, with understaffing issues and an increasing service delivery focus, the ability for psychiatrists in public practice to participate in teaching and research is at risk of being restricted. Private practice, with some exceptions in group private hospitals, provides even fewer opportunities for academic work, particularly given the limited remuneration. This disconnection from contemporary academia may be particularly isolating for early career psychiatrists, especially as they shift out of training, a time during which there is an intensive focus on exam preparation and evidence-based practice. As new consultants navigate this role transition, it is critical that they are given time and opportunities to maintain and develop scholarly interests, which subsequently facilitates the individual’s professional growth as well as the quality of care they are able to provide.

Conclusion

The issues touched upon here, somewhat anecdotally, suggest that there are a multitude of factors which can motivate our decisions regarding practice. Although senior trainees and early career psychiatrists are grappling with these choices because of their career stage, many of these issues affect all of us throughout our working lives. Often our expectations are not met, and combined with individual negative experiences, this may contribute to the insidious emergence of disenchantment over time. With recent concerns, there must be ongoing consideration regarding the challenges psychiatrists are facing now and those we may face in the future. These factors will have a significant impact on our professional workforce and the community we have made a commitment to care for.