De-skilling me softly: a cautionary ballad

Christmas Offerings

MJA 2000; 173: 661

To the tune of "My darling Clementine"

Once were doctors, we were doctors practising psychiatry,
Many long years spent preparing for this complex specialty.
Yet vital skills were clearly lacking post-FRANZCP;
Some sought more training and supervision in intensive therapy.
This for patients that politicians crudely scorned as "worried well",
Though some outwardly successful, their private lives an empty hell.

Chorus:
Oh psychiatry, dear psychiatry, shame what they have done to thee,
Evidence-based undertreatment, protocols for you and me.

Abe's¹ parents both were war survivors for whom a hug felt like a shark,
His wife and colleagues fear his rages; his son swaps needles in the park.
Sue's¹ father scorned her, uncle raped her, mother feared her infant cry,
A PhD, gym and many lovers, constant achievement keep Sue alive.
My old consultant taught his interns such patients need skilled care for years,
Perverse enactments, somatic crises, destructive mood swings, holiday fears.

(Chorus)

College leaders in New Zealand mock this profligate waste of time,
College leaders in Australia want us to toe the Kiwi line.
With SBE,² McKay³ and Tolkien,⁴ all government consultancies
Farewell depth of understanding, hail the glib technocracy.
Costed guidelines, sector funding, managers loom at the door,
Now are doctors health providers, integrated to the core.

(Chorus)

Psychologists and health diplomates give CBT⁵ and strategies,
GPs prescribe medication and short-term "cures" for anxiety.
The New Psychiatrist does brief assessments then supervises from afar,
Coordinating treatment modules, schizoid omniscience so bizarre.
Short-term treatments deemed "world's best practice", just deliver and you'll score
Academical promotion, fancy titles, gongs galore.

(Chorus)

Group therapy died when they closed outpatients, CL's⁶ been slashed, will it survive?
Complex skills lost or devalued by economic triage, political guile.
Dollars galore for administrators, publicity, consultancies,
Those least skilled in treating patients design and guide health policy.
Though Abe and Sue need long-term treatment, such skills dismissed as "luxuries",
Health-strategy oligarchy's newspeak is "evidence", "community".

(Chorus)

Soul-death, despair, basic trust, self-hatred, these DSM⁷ cannot define,
Only thoughtful understanding of patients' "I" and "you" through time.
But Canberra has plans and timelines at whose behest ambitions soar,
Though psychic pain crosses generations, demo projects this truth ignore.
Dare you oppose their naive hubris they'll dismiss it as elitist greed,
Those bureaucrats and academics who've never heard a psyche bleed.

(Chorus)

With platitudes and stats aplenty they'll prove how great a job they've done,
Then off they'll go to some bigger office or a salary package in the sun.
High talk of ethics, academic standards, yet which professor rose to protest
When these were crudely violated, 319⁸ was the first test.
How my heart is sick with anger, for Abe and Sue have been betrayed,
Bio-psycho-social wisdom has become a glib charade.

(Chorus)

From Maimonides, Osler and Bleuler, to Engel and Oliver Sacks,
To know the patient as a person guided wise doctors more than stats.
Interns now learn from their elders treatment's just a recipe,
Don't spend too much time with patients, call them "clients" and you'll see
That there's no need to understand what shapes a life from womb to grave,
The less explored their loves and traumas, faster the throughput, more money saved.

(Chorus)

Once were doctors, we were doctors practising psychiatry,
Now the tame, generic workforce of the health bureaucracy.
Understanding loss and illness or mind-body takes too much time,
Sacrificed to symptom checklists, rating scales and stats so blind.
Acronyms and showcase projects, Australia's mental health strategy,
Dictated by the performance values of global markets ideology.

(Chorus)

Edwin Harari
Psychiatrist
North Carlton, VIC

1. "Abe" and "Sue" are false names of actual patients.
2. Solomon, Buckingham and Epstein report (1993), subtitled "A consultancy report for the Mental Health Workforce Committee on medical workforce financing arrangements".
3. McKay report (1996), "Issues and options. Optimum supply and effective use of psychiatrists; a project for the National Mental Health Strategy".
4. Tolkien report (1994), "A model for matching the available workforce with the demands for services".
5. Cognitive behaviour therapy.
6. Consultation-liaison psychiatry.
7. Diagnostic and Statistical Manual.
8. Item 319, introduced in the Medical Benefits Schedule of fees in November 1996, limiting the rebate for psychiatric treatment.