An interview with Dr Rachael Cullivan-Elliott, Vice President for CME
What inspired you to become a psychiatrist, and what continues to motivate you in your work?
I studied Medicine in Trinity College in Dublin and my undergraduate placement in Psychiatry was in St Patrick’s Hospital – one of the oldest psychiatric hospitals in the world. It was opened in 1757 thanks to a bequest from the author Jonathan Swift. The patients I had the privilege of seeing during that time greatly sparked my interest. During a subsequent “summer job” with the Irish Medico Social Research Board (for 30 Irish Pounds a week!) I had an opportunity to work with the then Inspector of Mental Hospitals, the late Dr. Dermot Walsh. With another colleague we published a paper on the reporting of suicide that involved many broader discussions and my decision to train in psychiatry was made.
There was a personal aspect to that decision also as two close friends at the time suffered from major psychiatric illness requiring hospitalisation. The impact on their lives and families and the stigma they suffered was considerable and convinced me that things could - and should – be better.
That view continues to inspire me. So although I do believe that stigma has reduced and many new treatments and approaches have been developed that are more tolerable, I still see new challenges arising all the time for those suffering from mental illness and I still want to make a difference!
What do you find most rewarding about working in psychiatry, and what keeps you passionate about your work?
I sometimes joke that – to attract new recruits – we need a “glove in the bucket” moment. By that I mean that often seen shot in a movie – where the surgeon/obstetrician pulls off their gloves and tosses them into the bin as the grateful patient/new parents look on admiringly – the sign of a successful “job done”! The successes in the specialty of Psychiatry tend to be less dramatic and responses more gradual but we need to remind ourselves that we have saved lives – those of patients and others and we have improved the quality of those and other lives. Reflecting on that is what I find most rewarding about my work – at its simplest level it is the genuine satisfaction that comes from helping others and gratitude that I am in a position to do so.
I enjoy teaching and training at all levels – undergraduate, post graduate and assisting in the continuing medical education of colleagues – which is why I am delighted to be involved with the UEMS. I also stay involved with public education, special interest and various voluntary groups. The questions I am asked - including the challenges to the way services are delivered (or are not delivered!)- keep me on my toes and require me to stay passionate about what I do. There is nothing quite like a fresh perspective to help reinvigorate a determination to persist with something that is working or to find an alternative to something that it now appears is not!
How do you maintain a sense of empathy and compassion for your patients, even when dealing with challenging cases?
I definitely noticed a gradual increase in my ability to be truly empathic as I gained experience over the years and I think that mirrors my experience of those I teach. Initially it can be hard to grasp the depths of suffering that psychiatric symptoms can inflict and the limitations and devastation they can cause. Cases I found challenging when training no longer evoke the sense of helplessness I sometimes experienced then. The emotions that arise from having responsibility for something you feel unable to manage can stifle attempts to be empathic. This is why training can help to develop and maintain empathy and compassion although sometimes it can be hard to convince people! Of course there are times a lack of compassion or empathy can result from fear and frustration and at this stage in my career burnout can impact negatively. I can honestly say however that I still maintain a genuine interest in and concern for those in my care. It is a very privileged position to be in – where patients trust me with their most personal and at times painful thoughts and experiences and allow and trust me to intervene.
Even with the most challenging patients – including the very small number who are aggressive or particularly hostile - it is important to understand what lies beneath that behaviour. We must remember that those with serious mental illness have often had difficult lives and negative experiences with many opportunities destroyed by that illness. We would not choose to have their lives but might find ourselves behaving similarly if we had.
How do you stay current with advances in psychiatric research and treatments? What is your preferred way to engage with CME?
That should be an easy question for me as Vice President for CME in the Section! In order to maintain my Irish Medical Registration I am obliged to provide annual evidence of ongoing engagement in CME. Attendance at the Winter and Spring Conferences of my National Association (The Irish College of Psychiatrists) as well as International Congresses ensures I am updated on current research and advances in diagnosis and treatments as these often form a major component of such events. I maintain subscriptions to several relevant journals and during the pandemic became much more comfortable attending Webinars and using e-learning opportunities so it has definitely become easier to access the learning I need to keep my practice updated.
As President for CME I also review proposals for live events and e-learning modules that are seeking EACCME accreditation. This has provided me with an incredible opportunity to keep in touch with new developments as their champions seek to promote the adaptation of new therapies or approaches through scientific meetings and courses.
My involvement in teaching and in the examination of medical students and trainees in psychiatry has also been an excellent incentive to keep up with what is current!
Notwithstanding all the major technological developments however I still enjoy an opportunity to simply sit and read a well-written journal article followed by a “quiz” and I believe that face to face conversations/discussions/workshops are still one of the best ways to learn. The knowledge amassed by experienced colleagues is immense and robust questioning by those new to the Specialty is vital in ensuring a balanced view!
What do you see as the biggest challenge facing CME in the field of psychiatry, and how would you address it?
In the past there was less confidence in CME where it was funded by Pharma and vested interests but that has been recognized and is being addressed by the accrediting bodies such as EACCME who make it clear that CME activities must be free from Commercial Interest and bias. There is also increasing recognition of the need for practicing psychiatrists to not only maintain current skills but to adapt to changing demands and to be in a position to critically consider and potentially utilise newly developed treatments and interventions for the benefit of patients. The main challenge here is in ensuring that busy practicing psychiatrists have both the time and the resources to do this. Some of the adaptations to the Pandemic – virtual meetings and on-line learning – have increased access to CME for many and reduced costs including travel costs. My Predecessor in this role however noticed and drew attention to a significant gender imbalance in those leading out on CME. As a result EACCME will be including equality, diversity and inclusivity in its future considerations.
To address other challenges it is important to learn from models of good practice where CME is working well. A previous Working Group of the Section has looked at CME across Europe and produced a “snapshot” of how CME was operating in different countries just before the Covid Pandemic. We had observed differences including in how it was financed and whether or not it was compulsory. Harmonization is the major focus of the Section and working towards this will help us in meeting the challenges faced in ensuring quality CME as we learn from each other.
How do you see the field of psychiatry evolving in the coming years, and what do you see as the biggest challenges facing the specialty?
We are certainly moving away from traditional institutional care and developing more individualised approaches using community –based working with a recovery focus. Harmonisation in training for the benefit of patients is the objective of the Section and the development of a European Board Exam in Psychiatry will assist with this. The Section promotes awareness of the need to respect Human Rights in a specialty with a past history of restrictive treatments. The relevant Working Group in the Section plans to have a CME course on the topic at the next EPA Congress and the ultimate goal is that coercive interventions will be minimised and seen as a last resort rather than part of routine practice.
Artificial Intelligence (AI) is the big news story at present ( although I think psychiatrists will be a challenge to replace)and while remote consultations were a necessity during the Pandemic and have become more established, we are still too close to those events to know what the longer term consequences of this will be. It has been clear however that the value of the face to face interaction has not been diminished and we still need to work towards more effective and better tolerated treatments for the major mental illnesses. The use of algorithms and machine learning from large amounts of clinical data will certainly be part of our future.
The biggest challenges to future development are nothing new: Insufficient resources for psychiatric services, societal challenges including stigma, war and poverty, and a lack of sufficiently early interventions that might prevent the development of severe mental illness. I would also have to add from experience in my current practice, that recreational drug use - of cannabis in particular - is resulting in large numbers of young people presenting to overstretched psychiatric services with negative impact on all concerned.
If you had to give advice to someone considering a career in psychiatry, what would it be?
Go for it!
It is a wonderful specialty that can allow you to integrate every bit of your medical learning, knowledge and personal attributes resulting in an immensely challenging but enormously rewarding professional life!