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Clinical leadership is necessary to improve the performance of large public hospitals. Trainee medical officers (TMOs) are important stakeholders in organisation-wide initiatives that affect the medical workforce and support clinician engagement. This case study describes the development of a representative body known as the 'TMO Forum' within the Central Adelaide Local Health Network as a mechanism to promote engagement between medical trainees and the hospital executive to facilitate escalation and discussion of system-based issues. Over the past 8 years, this group has evolved into a community of practice with steady and sustained growth since inception. Trainees have fostered relationships with the executive, and have engaged in leadership and quality improvement initiatives. Here we explore the evolution, value and barriers to success of the TMO Forum. Our discussion is supplemented with findings from anonymous online evaluation surveys of both the TMO and executive stakeholder groups. We propose that initiatives such as the described may offer reciprocal benefits to both constituent groups regarding communication, and that the development of a dedicated community of practice will enhance engagement of TMOs in health service improvement initiatives and advocacy. However, there are obstacles to overcome in order to attract a greater number of trainees and maximise the benefits from this initiative.

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Parkinsonism is seen frequently in patients with psychiatric conditions. Drug-induced parkinsonism (DIP) is the second most common cause of parkinsonism in the general population after Parkinson's disease (PD) but a range of rarer aetiologies, some of them reversible, should also be considered in patients of all ages. DIP is more common in older patients, as are neurodegenerative diseases that may produce parkinsonism and it is relatively more likely that drug exposure could be unmasking an underlying process in this population. There is an extensive literature on differentiating DIP from PD but clinical features can be indistinguishable and many proposed investigations are not readily available. Aside from cessation of the responsible medication, there is no clear consensus on treatment strategies or duration of treatment. Practically, a delicate balance must be achieved between ameliorating parkinsonism and avoiding recurrent psychosis. Long-term prognosis in the setting of DIP remains unclear. We review the features that may differentiate DIP from other causes of parkinsonism in patients with psychiatric illness, provide an update on relevant investigations and discuss management strategies. The use of atypical antipsychotics for a broad range of indications highlights the ongoing relevance of DIP.

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OBJECTIVE: To describe a course for trainee psychiatrists, designed to encourage critical thinking within an interdisciplinary framework. Trainees' responses to the course, and the implications of these for teaching, learning and clinical practice, are considered. METHOD: Trainees were interviewed, and their responses subjected to content analysis. RESULTS: To some extent, the course appears to have met its objectives. However, some trainees found parts of the course content threatening, and reported negative perceptions of teaching staff and the process of critical appraisal. CONCLUSIONS: Challenging taken for granted beliefs in psychiatry is a fundamental skill, which should be fostered in trainee psychiatrists if the profession is to move forwards as an intellectual and clinical discipline. The lessons learned from the course we describe may be useful to others who wish to pursue integrated, interdisciplinary teaching methods.

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OBJECTIVE: This paper describes the introduction of formative feedback into a psychiatry attachment at an Australian university and evaluates students' responses to that initiative. METHOD: Students were provided with formative feedback sessions employing a standardized instrument, also used at the end of the attachment for summative assessment. They were asked to both define formative feedback and rate its usefulness on a questionnaire, providing open-ended written comments where appropriate. RESULTS: The concept and purpose of formative feedback were understood by 91.9% of the students who completed a questionnaire. The vast majority considered it to be useful, but some identified the need for constructive criticism and structured feedback as important characteristics of formative sessions. CONCLUSIONS: Rigorous research is needed to establish whether formative feedback impacts summative assessments. However, it is clear that such feedback is desirable, in that it increases student confidence and direction. We encourage our colleagues to consider introducing and evaluating formative feedback into psychiatry curricula.

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OBJECTIVE: Although the two political systems cannot be equated, the psychiatric and psychosocial issues raised by people detained under the migration regulations of the present Australian government, and those detained under the security legislation of the last apartheid government in South Africa, are similar in many aspects. METHOD: We present two case scenarios representative of the cumulative clinical experience of the authors in their work (as part of their routine clinical practice and medical school experience) with asylum seekers and political detainees in acute psychiatric units in both South Africa and Australia. RESULTS: Similar issues raised included the validity of a psychiatric diagnosis in these patients and the debate this conundrum provoked among the multidisciplinary teams. The pressures placed on clinicians by politicians in terms of clinical management of hospitalized detainees raised similar ethical questions across both countries. The clinical syndromes of depression and posttraumatic stress disorder were similar. The effect of the 'non-person' status conferred upon refugees by the 'temporary protection visa' could be equated with the effect of 'banning orders' imposed on opponents of the Apartheid regime. CONCLUSIONS: In South Africa, political detainees entered into the struggle expecting to face hardship and torture at the hands of the government of the time. Asylum seekers flee to Australia expecting support from a democratic system and generally had not prepared themselves for further incarceration and yet another political struggle. Despite this seemingly fundamental difference, the experiences of detainees across two very different political systems are remarkably similar.

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OBJECTIVE: In response to the identified need for up-skilling in psychiatry for rural and remote general practitioners, a series of workshops has been designed and delivered to medical and nursing staff in South Australia. In this paper one such workshop is described, dealing with acute psychiatric care. Quantitative and qualitative evaluations of the workshop are reported on, and recommendations are made for future training programmes. CONCLUSIONS: The workshop was well received and increased participants' knowledge about the management of acute psychiatric presentations. Qualitative data indicate that the pharmacological management and neurobiology of psychiatric illness was interesting but difficult for some participants, and further training in these areas may be appropriate in future workshops. Inclusion of all professional stakeholders in future training is recommended, including students, to promote interest in working in rural and remote health. Participants considered networking with colleagues as an important benefit of the workshop. Targeted training in psychiatry may be needed for overseas-trained doctors. Further, rigorous research is needed to evaluate the long-term benefits of up-skilling workshops, and to inform funding bodies as to where resources might be most effectively channelled.

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OBJECTIVE: The aim of this study was to assess an electroconvulsive therapy (ECT) rating scale by studying the intraictal electroencephalograph parameters induced by the seizure, and determine the clinical utility of such a scale in terms of time, application and ease of use. METHOD: This naturalistic study of 55 depressed patients over a 2-year period examined specific parameters of the intraictal electroencephalograph seizure morphology and computer printout, and their association with overall clinical outcome. The rating scale was developed and evaluated in terms of clinical reliability and ease of use. RESULTS: Overall, 1076 individual ECT treatments were given. Using multiple regression analysis, overall seizure adequacy correlated most closely with abrupt seizure endpoint, a high amplitude rhythmic spike and wave phase of >13 s, a seizure energy index of >1000 u, and an electroencephalograph seizure length of > 24 s. "Adequate" overall ratings as determined by the rating scale were shown to correlate significantly with overall clinical improvement. The rating scale had extremely high interrater and test-retest reliability; and was relatively easy to use and time efficient. CONCLUSIONS: The use of the rating scale has the potential to help clinicians optimize ECT. While not perfect in any sense, it still gives clinicians good predictive qualities when used as a clinical guide. It is important that larger studies look at all the potential variables that may interact with seizure adequacy and clinical outcome.

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OBJECTIVE: Despite the vast amount of scientific literature available on electroconvulsive therapy (ECT), there is little qualitative focus upon the patients' subjective experience of this procedure. Using an exploratory descriptive methodology, this study aims to provide a more unique insight into what certain patients actually think of ECT. METHOD: Semistructured interviews were conducted to explore eight patients' opinions and experiences of ECT. Interviews were subjected to analysis by a five-step framework approach that identified prominent themes in relation to five broad questions and in conjunction with issues raised by the subjects themselves. RESULTS: Eleven major themes were identified. Four of these were chosen for discussion, not only as the most prevalent themes (in terms of how frequently they were mentioned by the subjects), but also as the most striking (in regards to the intensity of emotions evoked, or their influence on their perception of ECT as a future treatment option). The four themes are fear of ECT, attribution of cognitive decline and memory loss to ECT, positive ECT experiences, and patients' suggestions. CONCLUSIONS: Using such a qualitative approach, the depth of the information obtained has revealed new perspectives on how patients perceive the experience of ECT. Fears reported by patients present an opportunity to address specific areas of the procedure that generate the most angst. These were closely associated with recommendations that many patients proposed throughout the interviews. Patients' perceptions of the cognitive effects of ECT do not necessarily correspond with those commonly reported in the literature on ECT. Positive experiences with ECT were more complex than simply its efficacy. There is a need for future research in order to explore and address patients' experiences of ECT.

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