Online medical student OSCE examinations during the first three years of the COVID-19 pandemic compared to three years pre-pandemic: An Australian experience in psychiatry and addiction medicine.

PURPOSE: We have evaluated the final-year Psychiatry and Addiction Medicine (PAM) summative Objective Structured Clinical Examination (OSCE) examinations in a four-year graduate medical degree program, for the previous three years as a baseline comparator, and during three years of the COVID-19 pandemic (2020-2022). METHODS: A de-identified analysis of medical student summative OSCE examination performance, and comparative review for the 3 years before, and for each year of the pandemic. RESULTS: Internal reliability in test scores as measured by R-squared remained the same or increased following the start of the pandemic. There was a significant increase in mean test scores after the start of the pandemic compared to pre-pandemic for combined OSCE scores for all final-year disciplines, as well as for the PAM role-play OSCEs, but not for the PAM mental state examination OSCEs. CONCLUSIONS: Changing to online OSCEs during the pandemic was related to an increase in scores for some but not all domains of the tests. This is in line with a nascent body of literature on medical teaching and examination following the start of the pandemic. Further research is needed to optimise teaching and examination in a post-pandemic medical school environment.

The changing psychiatry workforce in Australia: Still lacking in rural and remote regions.

INTRODUCTION: There is a long standing and worsening shortage of psychiatrists in Australia particularly in rural areas. The majority of psychiatrists work in major cities. OBJECTIVE: To identify recent trends in the Australian rural psychiatrist workforce compared with the metropolitan workforce. DESIGN: We descriptively analysed population-level data from the National Health Workforce Data Set (NHWDS), the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS). A descriptive analysis of the numbers (count) and gender of psychiatrists from 1995 to 2022 working in Australia was conducted. For the period 2013 to 2022, we analysed for rurality, gender, years' experience, hours worked, Medicare-subsidised services provided and proportions of Specialist International Medical Graduates (SIMG) by sex, with a focus on the rural workforce. For international comparison, psychiatrist numbers were obtained for other OECD countries. The number of psychiatrists working in Australia, as per NHWDS and AIHW, was quantified. We analysed trends in demographics, hours worked and rurality of psychiatrists working in Australia in a serial cross-sectional design. FINDINGS: Most psychiatrists are maldistributed to major cities, while outer regional and remote areas have few resident psychiatrists. Outer regional New South Wales (NSW) and South Australia (SA) have the lowest numbers of psychiatrists per capita. The full-time equivalent (FTE) of psychiatrists per 100 000 has increased from 12.6 in 2000 to 15.2 in 2022. However, the average hours worked by psychiatrists has declined. In total, available psychiatrist hours worked per 100 000 population has increased by 6.1% since the beginning of the millennium. DISCUSSION: Rural areas in NSW and SA have the greatest shortage of psychiatrists. Specialist International Medical Graduates and females (43% of the overall workforce) are the predominant workforce in rural areas. Although Medicare-subsidised services per 1000 people have increased in rural areas, they remain lower than for those living in major cities. CONCLUSION: There remains an acute shortage of psychiatrists in many regional and remote areas of Australia, with an increasing proportion of SIMGs and females working in these areas, in the context of future increased demand.

Physician leadership during the current crisis in healthcare: A perspective drawn from anthropological and clinical leadership research.

OBJECTIVES: There are ongoing challenges in workforce sustainability and service delivery due to the COVID-19 pandemic. Recruiting credible clinical leaders can enhance outcomes through mentoring, leading by example, and creating positive work environments. We investigate the anthropology of, and related research on leadership. CONCLUSIONS: Clinical and anthropological research provides strong grounds for investing in clinical leadership. The stability of 'prestige-based' leadership can be contrasted with the outcomes of 'dominance-based' leadership that relies on force, control, and threats. Dominance-based leadership increases the risks of bullying in stressed healthcare organisations. In contrast, expert clinical leaders can exert culturally mediated effects on social learning, team cooperation and morale, and patient outcomes.

Midsagittal corpus callosal thickness and cognitive impairment in Parkinson's disease.

People diagnosed with Parkinson's disease (PD) can experience significant neuropsychiatric symptoms, including cognitive impairment and dementia, the neuroanatomical substrates of which are not fully characterised. Symptoms associated with cognitive impairment and dementia in PD may relate to direct structural changes to the corpus callosum via primary white matter pathology or as a secondary outcome due to the degeneration of cortical regions. Using magnetic resonance imaging, the corpus callosum can be investigated at the midsagittal plane, where it converges to a contiguous mass and is not intertwined with other tracts. The objective of this project was thus twofold: First, we investigated possible changes in the thickness of the midsagittal callosum and cortex in patients with PD with varying levels of cognitive impairment; and secondly, we investigated the relationship between the thickness of the midsagittal corpus callosum and the thickness of the cortex. Study participants included cognitively unimpaired PD participants (n = 35), PD participants with mild cognitive impairment (n = 22), PD participants with dementia (n = 17) and healthy controls (n = 27). We found thinning of the callosum in PD-related dementia compared with PD-related mild cognitive impairment and cognitively unimpaired PD participants. Regression analyses found thickness of the left medial orbitofrontal cortex to be positively correlated with thickness of the anterior callosum in PD-related mild cognitive impairment. This study suggests that a midsagittal thickness model can uncover changes to the corpus callosum in PD-related dementia, which occur in line with changes to the cortex in this advanced disease stage.

Clinical update on public and private psychiatric practice shared-care partnerships - Can the twain work together?

OBJECTIVE: We explore the previous research and current context regarding opportunities for shared-care partnerships between public and private psychiatric practice. CONCLUSIONS: Since the early 2000s, when there was impetus for the development of public-private psychiatric shared-care models as part of a previous National Mental Health Strategy, there has been surprisingly little research and policy development. Given an apparent exodus of psychiatrists to private practice due to current challenges facing the public health sector, it is timely to reconsider models of private and public sector shared-care that may improve the quality of public mental healthcare.

Risk perception research informing recommendations for COVID-19 preventative health measures and public messaging.

OBJECTIVE: To provide a commentary on evidence-based recommendations for COVID-19 pandemic risk communication for more effective public health measures. METHOD: We apply the principles of risk communication to address key issues in the COVID-19 pandemic. RESULTS: Risk perception and communication research usefully informs preventative health education and public messaging during disease outbreaks such as the current COVID-19 pandemic, especially for those with severe mental illness. CONCLUSIONS: Key recommendations for pandemic public health risk communication are: clear, timely and balanced information from a reputable source; accurate and non-sensationalised depiction of infection, morbidity and mortality rates; awareness of fear as a powerful motivator for adoption of protective measures against the causative virus; promotion of self-efficacy and sense of control in terms of mitigating the health threats associated with a pandemic; correction of mis- and disinformation regarding the pandemic and associated protective measures; and messaging may need to be modified for people with a mental illness to avoid exacerbations of depressive and anxiety symptoms.

Medicare-subsidised mental health services from the beginning of Better Access in 2006-2007 to 2019-2020: Descriptive analysis by state, profession and consultation profile.

OBJECTIVE: Since 2006, the Australian Federal Government has aimed at expanding mental healthcare through the 'Better Access' programme of Medicare-subsidised services by private practitioners. We comment on population access to subsidised mental health treatment via health professionals in Australia. METHODS: We descriptively analysed Australian Institute of Health and Welfare (AIHW) data. RESULTS: Increasing percentages of the Australian population of people received Medicare-subsidised services from 2008-09 to 2019-20. Population access to mental health treatment increased from 5.7% to 10.7%. In 2019-20, psychiatrists provided services for 1.7% of the population, while GPs provided for 8.8%, clinical psychologists 2.2%, registered psychologists 2.9%, and other allied health providers 0.4%. Over the period, numbers of Australian psychiatrists providing services increased, but the numbers of patients seen per year, and other indicators, have either been flat or declined. GP, Psychologist, Clinical Psychologist and other allied health consultations increased overall, but again the numbers of sessions have decreased. CONCLUSIONS: Medicare-subsidised private practice has greatly increased population access to mental health treatment. However, there appear to be a relatively limited number of consultations per patient for most provider groups. Further research is required on the effectiveness of treatment through collecting data on casemix and outcomes.

Mental health services need action on organisational culture and justice.

OBJECTIVE: A commentary on the usefulness of the concepts of organisational culture, organisational climate and justice on the quality and safety of mental health services and how conditions may be improved. CONCLUSIONS: Organisational culture, organisational climate and justice impact upon the quality and safety of care, as well as well-being of staff, in mental health services. Psychiatrists and trainees, should consider, act and advocate for improved organisational culture, climate and justice. Improvement in these organisational domains can be achieved, through a coordinated framework that acts across all levels of administration, mid-level management and frontline clinical staff.

The Consortium of Australian Academic Psychiatrists for Independent Policy Research and Analysis (CAPIPRA): Aims, model, outputs, and implications for clinical academic advocacy.

OBJECTIVE: We describe an independent model of clinical academic mental health services research that is able to provide synthesised views for medico-political organisations that are engaged in advocacy for national and state evidence-based policy and planning of mental healthcare. CONCLUSIONS: CAPIPRA focuses on independent research and policy analysis using publicly available datasets on population mental health at national and state/territory levels, published in international and national peer-reviewed journals (>50 papers since 2019). We partner with medico-political organisations in evidence-based advocacy across a wide range of issues.

There's no sugar-coating psychological distress and illness perceptions in gestational diabetes mellitus: depression and anxiety are associated with negative illness perceptions.

OBJECTIVE: To gain an understanding of how women with gestational diabetes perceive their illness, and whether depressive/anxiety symptoms and/or psychological distress influence these illness perceptions. METHOD: A cross-sectional study was conducted with 159 pregnant women aged 18-44 attending gestational diabetes clinics. Participants completed a questionnaire, which included the Edinburgh Depression Scale (EDS), Kessler 10-item Psychological Distress Scale (K-10), Brief Illness Perception Questionnaire (BIPQ), and psychiatric/general health items. Multiple regression was used to explore the relationship between EDS (total and anxiety subscale) scores and BIPQ scores, as well as between K-10 (total and anxiety subscale) scores and BIPQ scores. RESULTS: Regression analysis revealed a positive association between EDS total/anxiety subscale scores and BIPQ total score, as well as between K-10 total/anxiety subscale scores and BIPQ total score, controlling for potentially confounding variables. There was a strong positive correlation between EDS total score and K-10 total score. The most frequently expressed concern about GDM was an adverse effect on their baby's health. A poor diet was the most frequently reported perceived 'cause' of GDM. CONCLUSION: Greater severity of depressive and anxiety symptoms, and psychological distress, is associated with more negative illness perceptions of GDM in pregnant women.

Maslow's hammer: considering the perils of solutionism in mental healthcare and psychiatric practice.

OBJECTIVE: To discuss narrow pragmatism, manifest as digital and technical solutionism, in mental healthcare and psychiatric practice. Pragmatism is a view of the field of psychiatry as an instrument or tool for the purpose of providing psychiatric care for people with a mental illness. Solutionism, as proposed by Morozov, can be considered a special case of pragmatism that valorises an approach to solving real-world problems based on computation, algorithms and digital technology,1 which we extend to discuss other technical solutions such as medication, non-invasive brain stimulation and psychotherapy. CONCLUSIONS: Digital or technical solutionism may unnecessarily constrain approaches to mental healthcare and psychiatric practice. Psychiatrists can consider, and should advocate for, appropriate adaptation of technology and technical solutions toward collaborative and effective mental healthcare.

Stiffen the sinews, summon up the blood, and strain upon the start: enfranchising the medical profession for clinically proximate advocacy of improved healthcare.

OBJECTIVE: To discuss and reflect upon the role of medical practitioners, including psychiatrists, as health advocates on behalf of patients, carers and staff. CONCLUSIONS: Health advocacy is a key professional competency of medical practitioners, and is part of the RANZCP framework for training and continuing professional development. Since advocacy is often a team activity, there is much that is gained experientially from volunteering and working with other more experienced health advocates within structurally and financially independent (of health systems and governments) representative groups (RANZCP, AMA, unions). Doctors may begin with clinically proximate advocacy for improved healthcare in health systems, across the public and private sectors. Health advocacy requires skill and courage, but can ultimately influence systemic outcomes, sway policy decisions, and improve resource allocation.

Recovery from anorexia nervosa: the influence of women's sociocultural milieux.

OBJECTIVE: Young women living in industrialised westernised societies have a higher prevalence of anorexia nervosa, partly due to a cultural emphasis on thinness as a beauty ideal. Sociocultural milieux might promote recovery from anorexia nervosa amongst young women. The current article is a commentary about the social influences on recovery from anorexia nervosa - based on social anthropology, narratives of people with lived experience, and clinical studies. CONCLUSION: Anorexia nervosa increases social withdrawal, and recovery leads to re-engagement with meaningful relationships. Recovery also empowers women as 'cultural critics' who challenge assumptions about the thinness beauty ideal and gender roles. The gradual process of full or partial recovery often occurs during emerging adulthood (aged 20-29). In this life stage, adolescent friendship groups are dissolving as women move from education to work, reducing the danger of weight-based teasing by peers, which is an environmental risk factor for disordered eating. Women recovering from anorexia nervosa may connect with those aspirations of peers and mentors that eschew a focus on weight and shape, but relate to the life-stage tasks of starting careers, beginning new friendships, selecting life partners and family formation - that is, a broader role in larger relationship networks.

Reflections on how to approach early career psychiatrist roles and challenges.

OBJECTIVE: To reflect upon and provide experiential advice to address the roles of early career psychiatrists. The main roles include leading patient care; working in teams; clinical supervision and governance of trainees, and of the psychiatrist by clinical directors/managers. While these roles vary across public and private sectors, the discussion focuses on common elements. CONCLUSIONS: The first several years of an early career psychiatrist's work often involves roles for which formal training cannot provide direct guidance, and which benefit from planning and reflective practice. Learning how to navigate clinical care, clinical supervision and governance, formal/informal mentoring and peer review are necessary to effective practice.

Greatly increased Victorian outpatient private psychiatric care during the COVID-19 pandemic: new MBS-telehealth-item and face-to-face psychiatrist office-based services from April-September 2020.

OBJECTIVE: The Australian Federal government introduced new COVID-19-Psychiatrist-Medicare-Benefits-Schedule (MBS) telehealth-items to assist with providing private specialist care. We investigate private psychiatrists' uptake of telehealth, and face-to-face consultations for April-September 2020 for the state of Victoria, which experienced two consecutive waves of COVID-19. We compare these to the same 6 months in 2019. METHOD: MBS-item-consultation data were extracted for video, telephone and face-to-face consultations with a psychiatrist for April-September 2020 and compared to face-to-face consultations in the same period of 2019 Victoria-wide, and for all of Australia. RESULTS: Total Victorian psychiatry consultations (telehealth and face-to-face) rose by 19% in April-September 2020 compared to 2019, with telehealth comprising 73% of this total. Victoria's increase in total psychiatry consultations was 5% higher than the all-Australian increase. Face-to-face consultations in April-September 2020 were only 46% of the comparative 2019 consultations. Consultations of less than 15 min duration (87% telephone and 13% video) tripled in April-September 2020, compared to the same period last year. Video consultations comprised 41% of total telehealth provision: these were used mainly for new patient assessments and longer consultations. CONCLUSIONS: During the pandemic, Victorian private psychiatrists used COVID-19-MBS-telehealth-items to substantially increase the number of total patient care consultations for 2020 compared to 2019.

Three perils of medico-political professional organisations: corporatisation, bureaucratisation and concentration of power.

OBJECTIVE: To discuss relevant factors affecting the effectiveness and membership engagement of medico-political professional organisations, for example, medical colleges, societies and associations. CONCLUSIONS: Medico-political professional organisations face perils from corporatisation, bureaucratisation and concentration of power that diminish membership engagement and influence. Actions to address these challenges are necessary to ensure the future viability of these organisations.

Tertiary eating disorder services: is it time to integrate specialty care across the life span?

OBJECTIVE: Australian tertiary eating disorder services (EDS) have a divided model of care, where child and adolescent mental health services (CAMHS) support patients until the age of 18 years, and thereafter, adult mental health services (AMHS) provide care. Consumers and carers have criticised this divided model because the age boundary occurs during the peak period of onset and acuity for eating disorders. Most CAMHS patients are lost to specialty follow-up around age 18, increasing the risks of relapse and premature mortality from eating disorders, since young women (aged 15-24) have the highest hospitalisation rates from anorexia nervosa. The current article is a commentary on the transition gap and possible service designs. CONCLUSIONS: Eating disorders require access to specialty treatment across the life span. The Australian Federal Government has expanded all-age care through the 2019 Medicare Benefit Schedule (MBS) eating disorder plans. Some new MBS patients require a rapid step-up in care intensity to a tertiary EDS, thereby increasing demand on the public sector. State/Territory Governments should strengthen EDS using the 'youth reach-down' model, where AMHS extend EDS to age 12. Vertical service integration from 12 to 64+ facilitates continuity of care for the duration of an eating disorder.

Conduct and evaluation of final-year medical student summative assessments in Psychiatry and Addiction Medicine during COVID-19: an Australian University Medical School experience.

OBJECTIVE: To describe and share with the medical education community, the conduct and evaluation of summative graduate medical student assessments in Psychiatry and Addiction Medicine during COVID-19 at an Australian university. METHODS: Summative assessments were redesigned as follows: written assessments were administered via an online platform (WATTLE), while the Objective Structured Clinical Examinations (OSCE) were conducted via a secure video-conferencing software (Zoom). RESULTS: Our preliminary analysis of the summative assessments indicated that both examiners and students adapted to the format, with overall performance of the students showing no variation due to timing of the assessment (earlier versus later in the day) and performances similar to face-to-face assessments in previous years. Examiners also expressed positive feedback on the assessment process. CONCLUSIONS: Our graduate fourth-year medical student summative assessments were effectively conducted using online and video-conferencing software in accordance with existing COVID-19 pandemic public health measures for physical distancing and hygiene.

Through the looking-glass: private and public practice psychiatry in the RANZCP.

OBJECTIVE: To provide reflections on the representation of and engagement with private practice psychiatrists by the Royal Australian and New Zealand College of Psychiatrists (RANZCP). CONCLUSION: We consider some of the reasons for private psychiatrist disengagement with the RANZCP. We suggest approaches to better engage private psychiatrists in the RANZCP, including: involvement in mental health policy, improved committee representation, specific private practice and business training for Fellowship, broader private practice peer support networks (welfare, clinical research, leadership), tailored professional development, branch-based networks of public and private psychiatrists, and collaboration with specialist medical colleges and the Australian Medical Association.

Student evaluations of teaching (SET): implications for medical education in psychiatry and an approach to evaluating SET and student performance.

OBJECTIVE: We present reflections on student evaluation of teaching (SET) in the context of recent higher educational research that assesses SET, as well as concurrent and/or subsequent student performance. CONCLUSIONS: In a sense, there is in-built cynicism in SET, with more favourable SET for easier assessment. There is emerging evidence that SET is inversely proportional to the performance of students in subsequent courses, i.e. the higher the ratings, the poorer the students perform in subsequent studies. It is proposed that SET should be combined with contemporaneous formative and summative assessments of student performance in medical school settings, especially in psychiatry education.