Psychiatry: Profession, Craft or Service?

Abstract

y first supervisor was a dedicated 'public' psychiatrist, fascinated by and committed to the treatment of those M forms of 'serious mental illness' that had filled the hospitals of his own training, and interested in developing adequate systems of case management and support for those patients. One afternoon a week he practised psychotherapy, his personal interest, which he also taught with great enthusiasm. He knew nothing of cognitive therapy and had difficulty encompassing problems of self-esteem (even when precipitating repeated self-harm and dysphoria) as 'real' psychiatry. Whilst happy to provide supportive psychotherapy in a range of situations he constantly reminded us that 'you can't make a silk purse out of a sow's ear'. I am sure he is quietly and tolerantly laughing from his grave about the splits and restructuring in our profession. I wish that I could practise as he did, but find the requirements of clinical leadership in an under-resourced general hospital unit too pressing, and serious psychotherapy remains an occasional if exhausting hobby.When I first came to Adelaide years ago I was surprised to hear a newly elected colleague complain that he was still doing too much 'registrar' work. He seemed to mean assessing and treating patients, documenting them, writing letters and liaising with family, GP and members of the team. I was surprised because I had thought that that was what our training was all about.Not that he didn't work, not at all. All the colleagues I have met work hard, albeit in different ways. For some it is juggling the requirements of teaching, research, funding and clinical time. For others it is the struggle to contain the anguish of one tortured borderline after another. For others it is trying to maintain professionalism and respect for patients and m o d e for the staff when the institution is over-run with work. For others it is plugging away, trying to maintain hope and keep inventing new options in the family of the chronically psychotic. Most who work in both camps regard their 'public' patients as 'harder', but they work hard on their private patients in different ways, and perhaps with greater satisfaction.And of course there is always more work. Most of the metropolitan public units and all the rural ones have been desperate for staff for years. A large number of our newly-elected Fellows move early into private office practice and all that do are booked out within a month and working long hourseven in South Australia where we are supposedly over-supplied. It is laughable that even when beds are available it can prove difficult to get a patient admitted to a private hospital because no-one is 'taking'. New community services develop complex (if simplistic) criteria to assess suitability of new referrals, so that scant services won't be 'wasted' on the less needy.During a recent discussion with a psychologist colleague I lamented that her private colleagues could not claim Medicare rebates, as I could then refer a patient to earlier and possibly &en more focussed treatm...

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