Autistic Psych

An autistic father training to be a psychiatrist

  • The Modified Essay Question

    There’s one last barrier examination I need to sit to complete my Psychiatric Fellowship. That examination is the modified essay question (alternatively called the “Short answer question exam”). This is a multi-hour, paper based exam where trainees are given clinical scenarios, and then have to answer a series of questions as to how they would approach those scenarios.

    A lot of trainees have collected questions over the years and passed them round. I’m very early into preparation for this, but the question file I’m starting to look through has about 600 pages. The earliest question recorded, dating back to 2014 (and perhaps showing some of the cultural focuses of the time), is this one:

    [I] You are a consult liaison psychiatrist. [patient] is a 53 year old secondary school teacher admitted under the medical team for new onset of neurological issues. He has had difficulty walking, memory difficulties, and he has not been sleeping, with irritability, and grandiose ideas. He believes he will cure the world of hunger through a new substitute food he has invented. Jerry is homosexual, and HIV positive for 30 years. The medical team are concerned that Jerry has become manic and are requesting your assessment.

    1.1 Outline your approach to assessment of the patient, including a cognitive assessment. (10 marks) [/I]

    On its own these types of questions don’t really worry me. Part of that is the structure of the marking key, whereby you gain marks for correct suggestions, but you don’t lose marks for incorrect ones. This is in contrast, say, to the multi-choice questions, where you have to discriminate a bit more carefully, the OSCE where you have to put on some degree of performance, or the critical essay exam where you have to fairly meticulously construct an argument.

    In the short answer exam, provided you know a reasonable amount about the management of each topic, you’ve got a reasonable chance to rack up marks.

    Beyond that, there’s also the advantage that the core initial assessment of most psychiatric cases are the same. You always gain collateral; you always assess risk; you always take a full psychiatric interview, you always consider multiple differentials that include the biological as well as the psychosocial…

    Even if you’re not an expert on a topic (such as the prompt for what is likely HIV dementia or HIV-associated mania), provided you have a broad exposure to the field and a good mental framework for approaching topics that are a little out of your wheelhouse, you can probably scrape enough marks to pass a question. If you have happened to work with a few patients with the condition, it’s quite considerably easier.

    HIV-related mental degeneration is a difficult thing to forget. I remember seeing a few cases back when I was a medical student. The unifying factor across them all was the sense of defeat from the patient that, after staving off a seemingly lethal disease for decades, that some part of it had finally caught them. These being short term placements, I never really had the chance to see how the patients ultimately came to terms with it, beyond a reliance on a type of dark humor that referenced the lethality rates of the disease pre-treatment in the early nineties.

    My memory jumps to individual cases very easily these days, often in very specific ways, and often producing a type of heaviness in my chest as it does so. It feels a bizarre mental shift to shake myself away from those memories in order to just extract the relevant bits of information for this suddenly less-important seeming test. Almost like it’s insufficiently respectful; to be using genuine experiences for the sake of something as essentially meaningless as a mark or two one way or another.

    On the other hand, this exam is renowned for having a fairly awful fail rate. It’s also one which has caught quite a few trainees who I considered pretty good doctors. And, although it’s been an increasing struggle for me to care about being a psychiatrist (as opposed to actually helping patients out, which is only sometimes the same thing) passing the exam does matter, I suppose…

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  • Camouflaging is real

    One of my psychiatric colleagues – a senior doctor who is generally fairly good – mentioned she didn’t believe in autistic masking.

    She continued with the following

    1. If you can do it almost all the time, it isn’t really a problem
    2. It’s something everyone has to do anyway

    This is, for me, a rather tiring conversation. The masking conversation always is, even when (as in this case), it is initiated with good faith.

    Thankfully, I am already out as a “diagnosed” autistic to this person, which makes things easier. Holding forth is almost always harder from within a closet. That’s not to say I’m entirely open about the extent of my autism. Even when I’m open, I work fairly hard to keep the reality of the difficulty under wraps.

    I’d start by noting that some degree of camouflage is necessary for almost everyone to socially survive. Fitting in is a social skill. It is vital for the easy formation of social bonds. For an autistic kid, it’s how we avoid bullying and social ostracisation (although that doesn’t always seem to work). It isn’t in any way fair, but it’s almost always the case that it’s easier to change the behavior of an individual than an entire social circle.

    So, everyone masks to some extent, and certainly more when you’re a minority group having to fit into very specific social stereotypes in order to safely advance. However, for a neurodiverse individual, there is an extra level of difference to traverse. We’re jumping across brain-types. Consequently, it takes both significantly more effort, and often consumes significantly more time than a neurotypical in the same social situation. The net effect is that the total cost for “living masked” is often greater.

    Some of these difficulties are mitigated through constant practice. Some autistic individuals I know manage this by observing young, observing often and practicing intently. This is deliberate mimicry to fit in. Again, this is not something unique to autistic individuals – instead, it is rather the extent and the intensity that makes it different. (Interestingly, the ability to imitate is often something that is well-preserved in autistic individuals.)

    As people age, these compensations often deepen in complexity. They still tend towards being formulaic, but they become both more flexible and more wideranging. They do not, however, necessarily become easier to enact. Things like stimming require active suppression. Outward emotional responses need to be constantly monitored and calibrated. It gets more familiar with time, but it never really becomes easy.

    I used to stim more overtly as a doctor, but after some criticism from my bosses, I’ve developed some routines with coffee cups instead. No one really fusses over a doctor who’s fidgety with coffee. Not stimming at all, in contrast, bugs me profoundly and isn’t really an option. In regards to the emotional stuff, with the help of my wife, I’ve learned to calibrate my reactions pretty well, and to lean into my inherent difficulties with affective empathy to help me out. Affectively limited, it turns out, doesn’t fall too far away from “jaded but sympathetic doctor” in the eyes of most people, particularly if you already look a bit tired.

    Most of these camouflaging functions require significant amounts of executive functioning to maintain. Given that autistic individuals are believed to often have greater difficulties with executive functioning, it stands to reason that maintaining such camouflaging is somewhat more exhausting. (It also suggests that autistic individuals with better executive function can maintain masking for longer periods without exhaustion). This could also be accounted for by the need for autistic individuals to continue masking heavily even in situations that others consider restorative.

    So, being able to mask almost all the time doesn’t actually make it less of a problem. Feeling you have to do it all the time is a problem, and probably a big one. Simply getting good at adaptively working around a difficulty doesn’t mean that the difficult doesn’t exist, any more than learning how to operate with minimal sleep obviates the need for sleep eventually. Masking most of the time is exhausting, and has been pretty clearly linked with poor mental health. Likewise, masking being a problem for a huge number of people with different levels of disadvantage does not mean it’s not -particularly- a problem for autistic people. Something being common does not mean it is not a problem. High blood pressure is not less of an issue because there’s more of it.

    Which is all.. Fine.. in a way. But it’s particularly frustrating when I hear these statements coming from an educated mental health professional who works with autistic people…

    Well, it makes me tired. Because it means I’m going to have this type of conversation again. And it makes me miss having other autistic people around at work, so I don’t have to go through it quite so often.

    * It has been suggested that females are diagnosed with autism less due to tending to camouflage better and earlier (albeit not necessarily at any lesser cost to themselves). On reading some of the earlier works on autism, I also wonder how much social mores simply came into it, even setting aside some of the earlier theories of autism as an inherently “gendered” disorder. Having just finished reading a book that discusses Asperger’s early cases, my attitude on this might be influenced by recency bias, so I’ll come back to this on another post.

  • Some kind of epilogue

    Being of a certain age, and being fairly close to reaching my consultancy, I’ve been looking back on my life and in particular my medical career. In light of this, I’ve queued up a post to capture my feelings as I contemplate sitting what might be the very last exam I ever do.
    Looking back – and it’s now very far back – it’s been a rather long trek and not an altogether pleasant one.

    Whilst I came out of it a relatively good doctor – I think – I’m not sure it was worth the sacrifice. I started studying medicine at the end of my adolescence (on the back for five years of fairly exam-focused high school), and in the context of my adding a third degree into the mix, I didn’t graduate until my mid-twenties.

    Since then, I’ve worked for the better part of eleven years, practising psychiatry until it feels as though the basic precepts are baked into my bones. A process that included years of sleep deprivation, overnights in hospital, and pacing long hospital corridors to learn the difficulties of tens of hundreds of people I’ve barely known ten minutes before.
    Rotating around and watching each of my consultants contradict eachother has left me both knowledgable about many aspects of psychiatry, and deeply skeptical about the foundations. Beyond the very basics – the treating of psychosis with antipsychotics, the choosing of medications based on empirical side effects, listening and being a generally kind human being- there is such a degree of supposition that often it feels like a best-guess scenario.

    I’ve listened to a huge number of stories, asked a lot of questions, and maybe given some useful advice. Over time, I’ve learned to pattern match, and I’ve developed the ability to pattern match things that work for one patient to another.

    I’m not sure I would have taken this path again. I’m not sure what my alternative is.
    In our training program, we do interviews at the end of most terms. Often with someone from the college, as well as a mandatory one with our supervisor. It’s been flagged that whilst I’m an excellent doctor, am very well liked, and have a very good research output for my career stage, I markedly lack ambition and drive.

    I even got asked to see someone for career advice and/or something psychotherapeutic about that. I was a bit worried about it for a while. Why don’t I feel more passionate? Why don’t I feel more driven?

    Truth is, I don’t really see being a doctor, much less being a psychiatrist, as core to what I do. I take pride in doing a good job, and I make sure to do right by my patients. I study almost every night – an hour, maybe two – and when I’ve got down time I listen to podcasts or read journals. I like to be up to date, and that probably means that I study more than most. But that’s just a part of basic decency. I’m fairly sure if I were a tradesman, I’d have exactly the same attitude about producing good product.

    To me, medicine is not a vocation. It’s not a grand or majestic calling. I wasn’t born to be a doctor, I simply chose to be one. And the path along the way was good enough, and the moral compromises generally minor enough, that I kept on going. And when on occasion the moral compromises were too much, my lack of attachment made it easier to stick my hand up, object and even willingly accepts setbacks in my training. Because compared to other things in my life, it just didn’t matter. None of my happiest moments have ever been in a hospital.

    What my career has done is allow me to support my family. I have a daughter I love dearly, and a wife I hope I’ve been able to give some measure of freedom to pursue the things she wants. She has given me great joy, and maybe that can be returned to her. Even when I know that some of the work I’m doing is of limited meaning, knowing that I can do that for my family provides a meaning. And if and when I graduate, maybe I’ll be able to do that whilst being home more, back in my comfy leather chair with a book or two, which is where I’ve been trying to get all along.

  • The lead-in to burnout

    I returned to work in February 2024.

    The last rotation, which had been public, had not gone well for me. There were some issues with the consultant, which are still a little bit raw.

    He’d been very hierarchical, which is uncomfortable, and paternalistic in his care strategies, which was even more so. The rotation was focused around home visits, which meant extended periods in the car making small talk. And his attitude for addressing weaknesses was to focus in on them, using something akin to an exposure-based methodology, balanced with the promise of a glowing recommendation at the end that could help to pass the CCA.

    Unsurprisingly, the exposure-based approach to reshaping the way our brains work doesn’t work very well for autism. You can’t just stick me in a big room filled with a bunch of birds and assume I’ll exposure-therapy my way to eloquence. So, even less surprisingly, I burnt out.

    I left with my dignity intact, apparently. Or so I’d been told. Even though outside of work, I’d been reduced to being a shambling husk, grimly holding things together in the face of a barrage of endless sensory stimuli in order to demonstrate I could manage just as well as any other registrar.
    Which I couldn’t, because not all registrars start lose their ability with words when they get too many reflective surfaces pointed at them for too many minutes. But then again, quite a few registrars were reduced to tears by this consultant’s general approach. Put charitably, he was adaptable at finding our weak points. When I dug back, I found I was far from the first to be in that position. One of the previous registrars had been a foreign training consultant, and they struggled even more than I did. I’m just the one who elected to quit.

    It wasn’t even the burnout which got me in the end. It was being asked to do something that I morally disagreed with – in its paternalistic, non-patient focused nature – and then being asked questions which would have got a colleague in trouble. Which I wasn’t ready to do, because one of the very basic things I’ve learned about leadership is that you don’t sell out someone doing the right thing just because someone in power is putting pressure on you.

    And so, when put on the spot – berated really – I put my head down and mumbled “Can’t do that”, and when I was asked again, I just repeated that a bit louder, no matter how many variations of “why” and “team cohesion” and “chain of command” got thrown at me.

    And when I was given an instruction that I couldn’t follow, I said, with what remnants of eloquence I could muster together “I don’t think I can ethically work with you anymore. This has broken down too much.”

    He backpedalled when I started talking about resignation. He was very ready to accept an apology (my apology, of course), to start again – all those types of things. But I set up a meeting with a head of service. Head of service requested I take a week to change my mind.
    I gave a week. During that week, my consultant was pleasant and polite to me. And then I indicated I still wanted to resign. Which surprised the head of service, because he thought the issue was resolved, as many people do when they just want a problem to go away. And he delayed, and talked about financial losses, and negative impacts to my career.

    And I said, I think this will be bad for my mental health. Bad things could happen.

    And he said, we’ll just have to address that if it happens.

    And I resigned, and I felt good about it.
    Also, one of the secretaries offered to knife the consultant’s tyres. Which I encouraged them not to do, because that was criminal and excessive, even if the consultant had been a colossal jerk. Though it was nice to know people there had my back.

  • A slow recovery

    I’ve been on a break from psychiatric work for a while now. Recuperation has taken a little longer than I thought. More than that, despite being rather close to the finish line, it’s a little difficult to want to go back.

    Medical school, as I’ve written, was a fairly tough experience for me. Being a doctor was somewhat easier, in that I was able to finesse situations significantly better so that my aptitudes came to the fore. Nevertheless, the job, and the degree of masking involved, is still a fairly punishing one. As a service registrar, it’s perhaps a little less bad. Psychologically, you still have some freedom. But once you’re in the training program, that changes. Rather like in medical school, you’re locked in. And perhaps worse than that, you’re locked in and at the significant mercy of whichever doctor has been allocated to be your supervisor.
    Giving one individual so much power means that training can be an arbitrary, capricious thing. It’s a system where a huge amount of trainee experience is dictated by personal supervisory character. And if you’re unlucky, it leads to a situation where, through a run of mismatches, a trainee develops quite a lot of psychological scar tissue.


    But that’s jumping ahead of myself. I should finish talking about medical school. The difficulties of what happen after that can wait for later.

  • An odd sense of foreboding

    There are days when, as I write in the lead in to Christmas 2022, I have an odd sense of foreboding.

    Like something bad out of my control is going to happen soon; a strange sensation of falling and falling.

    Hard to know if it has any meaning.

  • End of Term Assessment

    I withdrew from my most recent psychiatry term about two-thirds of the way through. This is a first for me, and apparently quite unusual given that I was apparently “passing comfortably”. Exactly how that happened is a long story, which I’ll probably get into later. Suffice to say, it had to do with my mental health, a boss with minimal insight, and extended amounts of exposure to some truly overwhelming sensory environments with minimal efforts to give me either accommodations or time to prepare.

    Anyhow, regardless of my having withdrawn, I was asked to complete an end-of-term assessment form. This was via a phone interview, which was probably for the best.

    The assessment form that gets filled out for psychiatric trainees is called “end of rotation in-training assessment form”, often shortened to ITA. It’s now generally completed electronically, but a PDF version is available. The document itself is about eight pages long.

    The first page is mainly records of how long the time in training was, and trainee indication that a minimum standard of contact was met. In particular, a trainee has to be in contact with their supervisor at least four hours per week. (I’ve had rotations where that has been touch and go and the college has intervened; with one in particular where a supervisor elected to move to a different town entirely part way through.) The second and third page lists completed EPAs and WBAs for the rotation.

    On the fourth through to sixth pages, learning outcomes are listed. The consultant puts a tickbox in each. There are thirty-two categories. Finally, the consultant fills out areas of strength and areas needing further improvement, which are something they discuss in greater detail.

    Areas of strength, for me, have been fairly consistent. I’m usually cited as having a very strong knowledge of psychiatry, being good with patients, and being good with treatment.

    Areas that I need to work on have, in contrast, been a bit more frustrating, if only because they tend to be things which are almost inherent to my autistic state. And quite often in these discussions, I’ve had to chat to make sure that a supervisor doesn’t write down things that are blatantly about autism.

    Things like my hand motions, which are stimming, or that I sometimes carry a cup of tea in order to mask them a little. Or that I have difficulty in large multi-disciplinary meetings, as it’s hard to follow when there’s a lot of conversation around. Or that I have difficulty with interviews ‘on the fly’, when I don’t have any opportunity to select the environment – like interviewing in bright sunlight without my having access to a hat and sunglasses.

    One of the worst parts is that, when I’ve asked how to address these types of things, the people giving the feedback can never give me a decent answer. Possibly because they haven’t thought any deeper than the obvious. But these are, after all, the people grading me. So I just nod, ask for suggestions, get the blank look – or sometimes the clearly worse “it’ll get better with practise” or exposure – and then try and end things. Because it really doesn’t work that way; or at least not for me.

    I can, in an emergency, push through almost any type of situation for a while. The sensory stuff hurts, but I can push through for a few hours at a time. Take a few minutes break, clear my head. Take some paracetamol; sometimes throw up. It hurts, but it’s possible. Sometimes I’d have fifteen hour shifts of that type of thing; stuck under fluorescent lighting with beeping pagers and yelling and hubub. And patients need you, so you just focus down – hyperfocus basically- and keep on. But it’s drawing on reserves the whole time, and instead of getting easier it tends to get harder. It’s less resistance training, and more someone punching at a bruise over and over, so it spreads and gets worse. And there is a certain mental threshold-toughness you can build from that, in an awful, self-neglecting way. But just because you learn to be ok with pain and self neglect doesn’t make it easier.

    I consider it a small personal victory that I’ve been able to quietly nod my way through all these evaluation discussions. I’m very glad they’re almost over.

  • Passing the CCA

    I recently got the results for my CCA (Clinical Competency Assessment).
    This is a fairly new type of assessment that’s conducted as part of the psychiatry training pathway.

    The CCA started as a short-term ‘alternative assessment pathway’ that acted as a substitute in 2022, but it appears to have transitioned into something a little more long term. It was initially introduced after the RANZCP was repeatedly unable to put together functioning remote OSCEs (Observed Structured Clinical Examinations – aka those things where you run through a whole bunch of fake 7 minute stations) during the COVID-19 pandemic due to technical difficulties. This led to a lot of trainees not being able to sit their examination, and a situation where quite a number of trainees had completed their training time and were being held up from graduating into becoming a psychiatrist predominantly because the RANZCP couldn’t arrange a suitable assessment.

    The CCA itself is composed of two parts. Firstly, there is a “portfolio review”, which involves a review of several of your end-of-rotation assessments. Then, if you aren’t judged to meet a certain (somewhat unclear) standard, you move onto a remote “Case Based Discussion”, which is essentially a type of viva where you write up two cases for submission to two independent examiners.


    Each case is 1500 words, and needs to be de-identified; you also need to have the patient sign the form to give consent.


    The examiners then read both cases, and pick one. The candidate then presents the case in a five-minute format, and then the examiners and the candidate discuss (or quiz) you on the topics raised.

    The whole process is conducted via teams or zoom, thus bypassing quite a few of the technical issues which held up the college.

    In terms of the specific questions asked, there’s a lot of guidance available for both the examiners and the candidates. There’s actually a list of forty-four questions which can be used as prompts, and which I suspect that most examiners would be drawing on fairly heavily.

    Overall, the Case Based discussion seems a fairly difficult topic for a prepared, moderately competent candidate to fail. You’re setting your own cases, you can prepare for most of the questions, and there are multiple markers.

    Regardless of whether you pass the CCA at the first stage or the second stage, the $730 fee for the examination remains the same.

    I managed to attain exemption from the case based discussion based on my portfolio review. Given that the review was based on things I’d done quite a while ago, it felt anticlimactic. Though, perhaps that’s a good thing. Heavy summative stress isn’t a great method of testing regardless.

    Whilst portfolios appear here to stay, I suspect that in the coming months there are going to be some modifications on what the portfolio will actually include. The topic of including the results of OCAs (observed clinical assessments of actual patients) that were assessed by external supervisors was considered. I’m not entirely sure of that myself – but I think that regardless of the specifics, using a sample of information broader than just the end term of term assessments would be a good thing. Have sat through quite a few by this point, I have an inkling that the ‘goodness’ or ‘badness’ of a trainee’s end of term reports is almost as much about the supervisor as the supervisee.

  • Essay Practice 2

    This was an essay that was typed, rather than handwritten, under time controls. I was starting to get into the swing of writing these at this point; I’d probably written a good half-dozen so I had a lot of references in my head. If I were to write it again, I’d separate up some of the longer paragraphs, focus a little bit more on ‘common fallacies’, and mention a little about who these ‘cognitive psychologists’ mentioned in the quote are. If I had a lot more time, I would try and tie the Kantian side of things in more tightly, and maybe sneak in a few memorable images. The intuition and metacognition, after all, are basically just Kantian proles and archangels in disguise…

    “Cognitive psychologists have shown us how our intuition can be fooled. We can be gullible. Critical thinking is required to avoid common fallacies. Metacognition can help us monitor our thinking and avoid mistakes.”

    Reference: Brush, J. (2013). The science of the art of medicine. ISBN 978-0-615-81132-1. p123. Used in February 2015

    Writing in 2013, Brush makes comment on one of the core difficulties of psychiatry – the failibity of intuition and the need for strategies to mitigate this. Whilst significant in any medical field, it is perhaps more so in psychiatry, given its broad coercive powers and historical abuses. Whilst a superficial reading speaks only to the limitations of an intuitive approach (which I here interpret as an understanding arrived at without recourse to deliberate conscious thought) and the benefits of metacognitive (which I here interpret as ‘thinking about thinking’) reflection, a deeper reading notes themes of the inherent fallibility and the limited falsibility of psychiatry, the risk of unconscious bias that can lead to injustice, the risk of the acceptance of social norms masquerading as ‘intuition’ that can perpetuate socioeconomic disadvantage. It sounds hopeful notes about the benefits of metacognition, but does not address the inherent limits of metacognition; namely that it is inherently inward focused and heavily dependent on the clinician knowing both his own limits, and having an awareness of information that he or she does and does not possess in order to yield effective outcomes. In this brief piece, each of these themes will be addressed, using a variety of clinical, ethical and historical lenses.

    Clinical intuition is a skill much heralded within psychiatry. One is often called upon to assess a patient from the moment one enters a hallway – on appearance, gait, demeanor and so forth, and feed all of this information into an intuition-led clinical gestalt. This speeds clinical process, but from a broader societal lens, mimics the controversial practise of profiling. We are, initially, judging a book by its cover. It is a process that, if unchecked, is liable to give free reign to countertransference or unconscious biases – a guilibility to ones own preconceptions rather than any patient-driven perception. At its most extreme, in the 1930’s such an approach led to psychiatric diagnoses of individuals based on perceived ‘Jewishness’ in Europe – or on projected psychiatric progress linked to the shape of ones cranium and suspected non-white ancestry in the United States. Even in the modern day, studies have shown that a simple glance at a patient’s prior diagnosis of ‘borderline’ versus ‘depression’ can significantly impact our interpretation of an identical situation- a judgement before we even meet them. Modern neuroscience argues memory is not static, but continually revised in a hippocampal-frontal refresh, leaving it constantly able to be modified by new information or even personal needs. The consequence of such needs might be particularly impactful when there is a clear advantage in recalling situations in certain ways- perhaps when when searching for exculpatory reasons to salvage ones own ego, or when justifying higher levels of restraint on a psychiatric locked ward whilst under a coronial critique . Indeed, such biases have been particularly noted in racial issues ,whereby individuals of different races are noted as more aggressive retrospectively than a contemporaneous video assessment supports – a topic of some concern given the overrepresentation of CALD in psychiatric populations. Without an error checking mechanism, intuition can thuseasily simply reflect prejudice, and perhaps even worse, can operate to modify our previous, more accurate understanding of situations.

    On the other hand, despite these limitations, the role of clinical intuition in therapy is well established. Most psychiatrists are familiar with the sensation of first feeling, rather than logically deducing, an aspect of the inner reality of a patient. This is part of the transference/countertransference phenomena, which lies at the heart of psychodynamic theory. However even in this situation, it is not the intuition or transference which is useful alone. It is instead the interpretation – in itself a specific type of metacognition- that yields insight. After all, knowing that you feel anger, and knowing that you feel anger because your patient is projecting this onto you due to past experiences are two very different things – and one far more therapeutically useful than the other.

    There are some psychiatric domains, such as suicide risk assessment, where intuition holds primacy. In suicide risk assessment, risks are largely drawn from history and actuarial tables, rather than being effective predictive tools for the specific patient on hand. This is in large part due to suicide being a rare event, which limits the strength of quantitative approaches. Consequently, even the most standardised tools tend to give strong weighting to the ‘feel’ and intuition of a clinician when it comes to elevated risk. Given the limitations of all other approaches, it is thus clear that, despite its limitations, the strong role of intuition in at least some aspects of psychiatry is needed.

    The core problem with intuition, then, is that its unconscious and inherently opaque nature leaves it highly vulnerable to bias. This presents a greater ethical problem in psychiatry than other medical areas, both due to the coercive power of psychiatrists, and the field’s limited falsifiability through nearly the entirety of its history. For example, one of the most common critiques of Freudian psychodynamics was that it was inherently circular; an argument that was refuted by Freudian scholars (in a ad hominem manner and paraphrasing Freud’s himself in his Clark lectures) as mere manifestation of resistance. More recently, Allen Frances argued that the DSM 5 was forged as much by pragmatic political compromise as scientific rigor. In other cases, whole diagnoses, such as schizoaffective, were maintained despite the writers lacking any faith in their reliability or face validity (Carpenter 2009). For the perspective of patient who is excluded from a disability support pension based on an intuitive ‘feel’ of how chronic an illness is likely to be, it would be entirely reasonable to raise objections – particularly if the psychiatrist themselves is arguing predominantly from intuition and thus leaving themselves open to the common fallacy of ‘argument from authority!’.

    Such concerns would be granted further legitimacy by the history of abuses in psychiatry, often driven by those who followed their personal intuitions beyond the bounds of evidence. Henry Cotton’s intuition that dental infections were linked to mental illness was followed to such a degree that thousands of unwilling inmates had their teeth removed- causing a spate of irreversible osteonecrosis. The Chelmsford scandal was driven by clinicians who felt deep sleep therapy was ‘safe’, all evidence to the contrary. Some of this may be due to the romanticisation of the lone-pioneer narrative within psychiatrist- such as John Cade rediscovering the benefits of lithium, but even in success stories such as Cade, it should be noted that patients died due to drug-related toxicity. A structured metacognitive approach whereby one hews to evidence may have mitigated all these.

    Is, however, the deliberate metacognitive approach sufficient? There are certainly limitations. Firstly, metacognition is cognitively taxing, and may interfere with task performance. (The difficulty balance between being both metacognitively self aware and fully engaged with your patient is a recurrent theme in therapeutic writings). Secondly, metacognitive strategies searching for flaws often involve negative self evaluations which may, if weighted too heavily, detract from well being and undermine self confidence. Thirdly, metacognition is inherently an inwards facing process – and cannot provide information that a therapist does inherently have. If someone, for example, does not know about the experience of being transgender, they cannot come to that understanding through metacognition alone. To use Kantian ethical terminology, metacognition is more analytic rather than synthetic. Thus, if a limitation of understanding is based on knowledge, it cannot be metacognitively fixed; the best one might hope for is identifying a self-contradiction that encourages a search for further clarification.



    A metacognitive approach, like any approach, needs to be utilised in balance rather than being viewed as a panacea. Indeed, we have a term for excessive and debilitating attention to metacognitive ruminations linked to an unhealthy mental model – that being OCD (Coles et al 2003). Instead, metacognition needs to be welded to specific, ethically oriented models to yield outcomes. One example of a model that would have minimised many of the historical injustices is the recovery model – with a focus on CHIME. Certainly, even a basic metacognitive check regarding connectedness or self-identity within a community would have given pause regarding the great, contemporaneously psychiatrically-endorsed modern Australian injustice of the stolen generation; as would have been even a basic respect for the rights of these freshly separated families or carers as laid out in the recovery model.

    Other tragedies might be better met through other models, such as the RANZCP code of ethics. For example, the Soviet diagnosis of sluggish schizophrenia, where psychiatrists intuitively ‘knew’ that someone was schizophrenic due to their political beliefs, regardless of absence of symptoms, would be prevented by RANZCP Principle six regarding politics and exclusion criteria for mental illness. Yet there are certainly limitations – whilst breach of ethical research principles is prohibiting by principle 7, in an extreme situation such as Nazi Germany, there remain socially determined limits on what one can safely do. Within a free society, a psychiatrist would likely be called upon to advocate for the rights of the disadvantaged and through application of expert knowledge to shift governmental positions. A reflective psychiatrist in an authoritarian eugenicist society, however, might further consider the limits of their expertise, and consider that certain actions or diagnoses may be detrimental to their patients – weaving the fine line between harm mitigation and collaboration whilst still adhering to core medical beliefs. One need only look at the recent reports on Hans Aspergers (Slagstad 2019) to see how easily it is cross that line. In such situations, a broad, transcultural ethical model – such as the four pillars, which provides ‘baseline’ principles such as autonomy, justice, beneficience and non-malificience to hew towards rather than clear dictates- might be more useful. It should nevertheless be acknowledged, however, that in such extreme social cases, identifying a problem permits a solution, but does not provide necessarily it.

    In summary, then, what is the role of the psychiatrist in all this? It is clear that intuition is a powerful tool, but that it is easily led astray by bias and preconception. Metacognition acts as a partial risk mitigator, but has numerous limitations unless linked to a strong ethical code and model. A psychiatrist cannot assume that metacognition on its own is sufficient. Instead, they should maintain an attitude of continual openness to new information, and be open to correction of both their metacognition and intuition when new facts are available. They should additionally be acutely aware of the priveleged nature of their position, and how ingrained medical and social hierarchies can limit the data provided to them. Bearing this in mind, on a broader level, and in a sufficiently free society, they might seek to use critical faculties to undercut predjudice masquerading as intution in mental health issues – as in the case of mental health stigma, or when adverse outcomes occur to patients based on demographic factors. Finally, a wise psychiatrist would keep in mind when there are problems which are beyond them – past both the realms of their experience, intuition and their metacognition, and in such circumstances be able to set aside their ego and seek assistance.

  • Getting rid of the OSCE

    The royal college has, as of 2023, decided to get rid of the OSCE component of the psychiatric examinations.

    OSCE, for those who don’t know, stands for Objective Structured Clinical exam. It’s a technique for examination pioneered back in the 1970s, and something that most recent doctors have had to endure all the way back since medical school. In some universities (including one I did OSCE examinations for) it starts as early as in the first year.

    Essentially trainees cycle through a series of simulations of clinical scenarios. Each simultation has a small prompt, and some general guidance as to what to do. You spend about seven minutes in a room, typically with an actor and a silent examiner. And then, after the seven minutes are up, you cycle into another room with a new station in it, whilst the marker evaluates you based on an entirely standardised set of criteria.

    It’s a fairly exhausting process for all involved; when I examined for the medical student OSCE the students were at it for three hours. It’s also, for psychiatry in particular, not a very good metric of practise. Whilst I can see the utility in some other medical fields, in psychiatry doing almost -anything- in under seven minutes is impractical. As a consequence, rather than assessing a practical, clinical skill, you’re instead largely testing trainee psychiatrists on their ability to a) rapidly identify the needs of the station and b) recall a fairly superficial bullet-point level of knowledge that matches the station. (As the actual marking is highly standardised, in most stations there is very limited ability for the observer to test the trainee’s knowledge base).

    At a student level, an example of an OSCE might be ‘please assess this patient for symptoms of depression and associated mental health conditions’, where marks would be given for rapidly running through common symptoms of depression, screening for anxiety and OCD, checking for drug or alchol use, checking for social contributors and finally screening for suicidality. At a trainee level, the station might be more complex – I recall one station where you were to roleplay as a junior consultant who had been called by a surgical nurse who was irritated by a patient with self-inflicted burns who had borderline personality disorder. The nurse would open with a line such as “I’m glad you’re here- we really need you to sort this person out” and follow on with statements about a patient being “one of yours”. Over the following seven minutes, a trainee would have to gather relevant information, de-escalate the situation, explain the mechanisms underlying the staff and patient’s difficulties (such as splitting), describe strategies to manage the issues (consistency, pain relief), and also reduce stigma against mental health patients. There’s probably about thirty seconds available for each point if you want to get good marks, and actually precious little time for actually listening to what the other party is trying to say.

    (For myself, whenever I go through an OSCE there’s been a part of me which wants to give slightly nonsensical responses. Luckily, I’ve only ever given into that during mocks. )

    My overall opinion of the OSCE, having been on both the student and the examiner side, is that it is a setup which heavily prioritises breadth over depth; that its time constraints limit its face validity in assessing outcomes (as ‘good psychiatry’ simply does not occur in seven minute blocks), and that by expecting our trainees to practise heavily to a seven-minute time scale we may be inadvertently teaching them to devalue other significant elements of psychiatry, such as rapport building, robust and well structured history taking. It also creates a setup where one is rewarded far more for speaking than listening. I wonder if, perhaps, if we are seeking to test those types of skills, they’re better tested in a inherently one-way written examination. (Whilst I note that the OSCE exists to allow a trainee to ‘show how’ to utilise a specific skill, in psychiatry I feel it operates at a lower level – that of merely ‘knowing how’, as much of what occurs in an OSCE is performative signposting rather than actually practising psychiatry).

    The other factor that I consider is that, for both students and trainees, OSCEs are excruciatingly stressful experiences with all-or nothing results. In medical schools, where failing an examination can mean repeating a year (or exclusion from a course), the amount of stress associated is horrific, and it’s actually not uncommon to watch otherwise competent student melt underneath the pressure of both the ticking clock and the knowledge of what might happen if they fail.

    There’s an argument that’s often been made that being a doctor requires tolerance of immense pressure, and that high-stress situations like OSCEs help develop that. That’s never been something I gave great credence to. Pressure tolerance, I have observed, is a fairly situation specific thing. Whilst tolerance can be developed, it needs to be done through a gradual type of supported exposure to situations that closely mimic the stressors of real life. Exposure to artifical stressors, in contrast, simply trains people to develop a tolerance to something else entirely – in the psychiatric case, further OSCEs.

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