I’ve always had an interest in the way people think, and a broader interest in systems and society, as I suppose many emergency physicians do.
There are mental health professionals in my family. My great-grandfather was the medical superintendent at the Peat Island Asylum, on the Hawkesbury River just north of Sydney, in the 1950s and ’60s. One of the buildings and a nearby inlet are named for him. I don’t think it was a happy place. I wonder if my determination to do better with mental health in emergency departments springs from an urge to make historical amends with his patients, even though those were very different times.
My dad’s oldest friend is a clinical psychologist who spent his career working with adolescents experiencing early onset psychosis. I have enjoyed many a ‘beer-o-clock’ with Michael discussing friends, work and current affairs. Every conversation concludes with him asking ‘aren’t people interesting?’. His rhetorical question is an excellent reminder of the fine line between so-called ‘normal’ behaviour and insanity. I think we clinicians always need to bear this in mind.
Like many doctors, I’ve had my share of mental health moments. On one occasion I required significant time off work. I’m lucky – I have never experienced a crisis acute enough to require hospital attendance. Mostly because I have a large network of family and friends, reliable employment, and the financial means to seek help early enough to get myself out of trouble. I have supported friends through emergency presentations. And, of course, I see the system close-up every day. I know that not much separates me – us – from our patients. And I know that I would not want to be a patient in the system that I work in.
I deliberately moved around as a trainee, and I saw how things worked in different places. In my first few years as a consultant, I worked at three hospitals. The most striking difference between the departments was the way patients presenting with mental health symptoms were managed – both processes and prevailing attitudes. At the smallest place, the inpatient unit was off-campus, which meant that mental health skills were core business in the emergency department. The other two hospitals had psychiatric emergency care centres (PECCs), which had been rolled out across New South Wales in the mid-2000s. Models were variable and the two units functioned quite differently.
When I eventually scored a staff specialist position at Royal North Shore Hospital, I was assigned mental health liaison as my portfolio. I’m sure it was a booby prize. Nonetheless, I discovered there was good stuff to be done. I worked with the PECC director to implement the NSW Mental Health Triage Tool. He developed education sessions for the emergency trainees about common mental health presentations. In return, I taught the psychiatry registrars about important physical problems, including diagnostic test selection and how to read an ECG. We held regular liaison meetings to review cases and processes. To my surprise, things started to work better – just by listening, talking and building relationships.
In 2015, I became director of emergency medicine at Hornsby Ku-ring-gai Hospital, on the northern outskirts of Sydney. The PECC is co-located but functionally separate from the ED, operating as a short-stay mental health inpatient unit. Hornsby is a district hospital, but has tertiary mental health services on-site, including the mental health ICU and a child and adolescent inpatient unit. Mental health admissions are disproportionately high compared to ED presentations – averaging 25 to 30 per week. Access block is a major challenge. The single after-hours psychiatry registrar has a near impossible workload, covering 63 acute beds spread across a large, dislocated campus.
I got there and figured it was time to start again, building relationships and working towards a common purpose.
Mandatory violence prevention and management training for ED clinicians was rolled out across NSW in 2016.
It was fantastic to see a focus on workplace safety, but the training got me thinking about structural causes of violence and aggression in ED and potential strategies for upstream prevention. I decided to learn more. I read reports and papers. I talked to people. And when I looked beyond the ED, I started to see things quite differently.
About seven per cent of presentations to NSW emergency departments are due to primary mental health symptoms. This is slightly higher than the number of patients presenting with chest pain. The morbidity and mortality experienced by these patients is higher too. I’d like you to reflect on the relative amount of resource and training we allocate to each of these groups. When I went looking, I found next-to-nothing about how to manage mental health symptoms well in our textbooks – the focus was on sedation strategies and security.
And mental health was almost missing-in-action from the fellowship curriculum and conference agendas as well. I decided to change that. I offered to speak about mental health at the Spring Seminar. The response was enormous. Clearly, I had identified a gap or at least hit a nerve. Within no time, I had received six further invitations to speak on the topic of emergency mental health.
A call for mental health champions went out via ACEM faculties in autumn 2018. It seemed obvious that I should put up my hand. An unwanted staff specialist portfolio and a single talk at a conference had opened a floodgate of policy and advocacy opportunities. The NSW Faculty Chair expressed concern that taking on more might not be good for my own mental health. However, this is such a big problem for patients and clinicians in ED that it felt good to be doing something constructive about it. I decided to take the role very seriously. I attended meetings, joined local and state mental health working groups, contributed to reports, engaged with government and met politicians. It has been challenging, at times, but also very rewarding.
I attended the ACEM mental health summit in Melbourne in October 2018. The day brought diverse stakeholders together – there were ups and downs, and there was some initial cynicism and suspicion in the room. Despite this, it was wonderful to hear about innovative models of care – the Behavioural Assessment Unit at Royal Melbourne, the PANDA (Psychiatric, Alcohol and Non-prescription Drug Assessment) Unit at St Vincent’s in Sydney, the Emergency Psychiatry service at The Alfred, The Royal Perth Hospital Homeless Team, and the Safe Haven Cafe at St Vincent’s, Melbourne. But the best thing, by far, was hearing the lived experience of consumers and carers. I learned about peer support workers – a workforce that has existed for a long time in mental health settings but is under-utilised in ED. I came away convinced there are easy things we can do better without massive investment of resources. And I found a couple of big-ticket items to aspire to as well. ACEM has put mental health system redesign firmly on the national policy agenda.
I was proud to be chosen as the token Aussie to participate in the New Zealand mental health summit in June 2019. The tone was quite different to the Australian version, especially given the recent announcement of the ‘wellbeing budget’. There were more new ideas – specialist mental health teams embedded in the emergency services, true integration of mental health with drug and alcohol services, and Māori-led programs based around story-telling and culture. A German-trained psychiatrist told us of his surprise at the artificial body/mind divide present in Australasian mental health training. He suggested that psychiatry trainees should do more medicine and ED trainees should spend time in psychiatry. Like the Australian summit, it made me realise how many simple things we might do to look after our patients so, so much better.
So, what have I learned after a year and a bit as one of the ACEM mental health champions?
The most important learning is that we need to view the behaviour of others through the lens of empathy. The psychiatry registrars at my hospital have a very difficult job, which they do with different training and expectations to mine. I need to think about their context when I engage with them, not just the priorities of my own service. I need to build shared understanding. The same goes when interacting with our patients, their carers and communities. We need to think about how they feel, what they perceive and what’s important to them. Because we are dealing with real people, with thoughts and feelings, not just problems to be solved.
The next big learning is that we can’t do this alone. Any meaningful change requires full participation of ED and mental health clinicians, consumers, their carers, general practitioners, community-based clinicians and social leaders. We need to drop the silos and tribalism. We need to observe the principle ‘nothing about us without us.’
Most of our patients have multiple diagnoses – mental health, addiction, behavioural and medical. We need to build models that allow for this; a return to generalism. And that will involve all of us working together. We need to train and educate health professionals to treat our real patients, not imaginary patients in textbooks with single-system problems. This will require a complete re-think of our curriculum and assessment methods. It strikes me that there is a lot that might be done with simulation in the ED mental health space – to improve our interactions with patients, to test-drive new systems and processes, and to learn how to work more effectively with other clinical teams.
The final learning is that we need to reconsider our notions of safety and risk. Because the way most ED clinicians think about risk is meaningless to our patients. Keeping people ‘safe’ by using seclusion and restraint is causing them harm. Through listening to lived experience, I now have a true appreciation of the importance of least-restrictive practice and trauma-informed care. I’m not sure that this can be achieved through online training modules – it is best learned through conversation. Luckily, we all have plenty of opportunities to engage with people with lived experience of mental health problems. And I know that it’s not easy to avoid restrictive practice in the system as it is currently working, so we need to collectively start imagining how we might do things differently.
I am also much, much more aware of bias and prejudice in our system than I was at the start of this journey.
Clinicians are not comfortable with things that make us feel vulnerable. And things that we don’t understand. And things that don’t fit neatly into a checklist or flowchart. And people with different cultures and beliefs. And people that don’t follow our rules. Think about how you run the ward round. Do you walk past the mental health patients and discuss their treatment at the end of the next bed? It’s not good enough. I reiterate, empathy and collaboration, especially with patients and carers, are key to developing better processes. Every policy or guideline that we use should be co-designed with consumers. Patients must be at the centre of everything that we do.
I’m very proud to have been involved with this body of work. I’m proud of ACEM for forging a path into difficult territory. I have learned a lot, met inspiring people, developed my ideas and grown as a person.
We work on the edge. We see all of humanity. We feel the cracks in the system. We meet people on their worst days and we know how easily lines can be crossed. We need to be social justice warriors – because our skill and experience can drive important structural and cultural change for good.
I would like to thank ACEM for this amazing opportunity.
Clare Skinner is Director of Emergency Medicine at Hornsby Ku-ring-gai Hospital in Sydney, NSW, Australia. Her professional interests include health system redesign, medical education and improving hospital culture. She is on a gazillion committees. In her spare time, she writes stories, plays music, makes bad art and hangs out with her partner and kids.