Funder by the Department of Human Services Auspiced by Our Community

A CONSUMER'S GUIDE TO EMERGENCY DEPARTMENT STAFF

Student, medical officer, registrar, psychiatrist, consultants - it's important when we are in hospital to know the difference between these different roles in the hospital hierarchy.

All of the people performing these roles (except the medical students) are qualified medical doctors but they do not all have the same power, responsibilities or time on the ward or unit.

It's important to understand the roles of the different doctors (and other staff). If we don't understand this we can spend a lot of time and wasted effort asking questions and trying to get responses from people who do not have the authority to give us answers.

It's OK to ask anyone who is introduced as either 'a doctor' or 'your doctor' whether they are a medical officer, registrar or consultant (or indeed a student). Unfortunately, few doctors will divulge this sort of information voluntarily.


Medical officers

Medical officers are generally in their second year post-graduation. That is, they have spent five years as medical students studying in university and in hospital placements. After this they would have done one year as an intern, being rotated around different areas of medicine in a hospital setting. The following year they would have gone on to become a medical officer.

Medical officers do not necessarily have an interest in psychiatry as a speciality; they do not stay in any setting for very long.

Medical officers will often be called 'the doctor' but it must be remembered that they are very inexperienced doctors who will be able to perform routine tasks but will not have the experience to make important decisions about our care.

It's also worth noting that medical officers are rotated frequently so on many occasions you will be dealing with someone who only started their rotation in psychiatry three or four days previously. This magnifies their relative inexperience and makes it even more important to understand their limitations.


Registrars

A registrar is the main doctor you will see when you are admitted to a public psychiatric Unit. The registrar will also play a major role if you use a public Community Mental Health Services.

Registrars are trainee psychiatrists. The traineeship lasts for at least five years and is supervised by the Royal Australian & New Zealand College of Psychiatry (RANZCP).

Registrars are more senior than medical officers; however, they are not yet qualified or registered as psychiatrists. Often patients do not know that the registrar is not a qualified psychiatrist.

They have more experience, greater responsibility and more power than medical officers but their power and authority is still limited. However, unlike medical officers, registrars have already made the decision to specialise in psychiatry so we know they have an interest in the area.

Registrars are always supervised by and under the guidance of qualified and experienced psychiatrists - called consultants (see below).

They will often be introduced as 'your doctor' and they will be on the ward and visible much more frequently than the consultants. They will have a 'list' of patients who remain under their care during the patient's stay in the unit or on the ward, during which time they will be mentored, critiqued sand assessed by the consultant to whom they are assigned.

Registrars will record anything you say and do and will feed this back to the consultant who will be the one making the most important decisions about your life.


Consultant psychiatrists

Consultant psychiatrists are the top of pecking order in terms of clinical care. This does not mean they are top of the pecking order when it comes to management of the psychiatric ward or unit; that role usually goes to the unit manager.

Unlike registrars, consultant psychiatrists are qualified and experienced psychiatrists. They are often psychiatrists who have their own private practice and work a number of sessions (shifts) in a public psychiatric unit each week.

When you are admitted to a public hospital, you will be formally admitted by the consultant psychiatrist. (If you are admitted to a private hospital you will be admitted by your own psychiatrist.)

Once you are admitted you will go on to what is called your consultant's 'list'.

Consultant psychiatrists are the big guns in our care for the time we are in hospital and yet we see them much less frequently than we see registrars. This is the same in all fields of medicine. When the consultant psychiatrist interviews you the registrar will probably sit in. They are there to learn and most times they will take notes that will be committed to your file.

Consultant psychiatrists are often drawn to work in the public sector because the position gives them the flexibility to do research, or they may have a particular interest in training new graduates, or they may have a particular commitment to public health.

Sometimes consultants will ask you whether you will consent to being involved in some research project they are interested in. Think carefully about this request. Your decision and reasons for making it could well be similar to your reasons for saying yes or no to requests for student doctors to sit in on an interview (see below).

Many of us forget the names of the consultant psychiatrist because we are introduced when we are in the first wave of admission. Don't be too embarrassed to get someone to write down the name for you. Things like addressing people by name are a good way to gain some control over the situation, as is making a rule to always shake hands and introduce yourself to any doctor you are seeing for the first time and (as a power-up ritual) each time you meet.


Student doctors

You will recognise the undergraduate medical students because they travel in packs. They're also easy to spot as they are generally as frightened of you as you are of them!

Students will usually be escorted by the consultant psychiatrist, and you should assume that they will have been given access to your medical file even if you have not given your permission.

Student doctors do not necessarily have an interest in psychiatry (they will need to study this aspect of medicine as part of their training, whether they're interested or not), but they will have an interest in impressing the doctor who is interviewing you.

The consultant psychiatrist will call them together after speaking with you and will quiz their knowledge about psychiatry by asking them questions about your 'behaviour', 'ideas', 'diagnosis', 'treatment' and 'prognosis' (how long it will take you to get better).

Your permission should be sought first if students are to sit in on your interview with the consultant psychiatrist. It's OK to say yes or no, to ask questions about what it involves, or to make some conditions.

All these reasons for saying yes or no (and others we haven't thought of) are fine. You don't have to justify your decision to anyone and you can say 'no' regardless of whether you are an involuntary patient.

Yes

Some of us will agree to be interviewed in front of students because we:

No

Some of us will say no to allowing students to sit in on our interview because we:


Hospitalists

In some states qualified general practitioners (GPs) are employed in emergency departments as 'hospitalists'.

The role of the hospitalist is to learn about the movement of people through the emergency department, identify 'regulars', and work with those of us who need to visit emergency departments very frequently for a variety of reasons.

The goal is for the hospitalist and 'patient' to find new and more sustainable ways to get very real needs met.

At the time of writing, there were no hospitalists in Victoria but the model has worked well in NSW.


E-CATT Teams

Working alongside the doctors in many hospitals around Australia, and all large emergency departments in Victoria, are the E-CATT (Emergency Department Crisis and Assessment Team) nurses.

This service runs 24 hours a day in most public metropolitan hospitals. The E-CATT nurse is, amongst other things, required to assess every person who has self-harmed, taken an overdose, has a mental illness history, or is simply known to the staff, before we are discharged.

This pushes the limits of the very small E-CATT team. Delays can result and this often annoys other emergency staff who need the bed and don't need us hanging around waiting. The situation can escalate when we are seen to fit into that group not believed to have a 'serious mental illness'.

Understaffed E-CATT teams can also get pressure from other clinicians to push us through, leading to a cursory glance and discharge. When this happens after a suicide attempt it leaves us with a range of feelings, from bitter self-hatred to helplessness to anger.

Unfortunately it can also lead directly to a subsequent suicide attempt - and maybe a much more dangerous one. It's not our fault that emergency departments are not designed respectfully for us. The chaos of the setting and emotional crisis is a dangerous mix, and is often too much for what the E-CATT nurse (often just one) on duty.