I would like to thank the fourth year medical students for their engagement on Tuesday at the Adolescent Skills workshop.
Miranda and I really enjoyed teaching you and we hope that you have found the tools and strategies that we have provided useful.
I would appreciate your feedback as to how this workshop may have assisted you during your time in general practice.

My day at Don College was really valuable. I would say try and sit in as much as possible. If you have nothing to do over lunch see if you can meet and have a chat with the social workers and learn a little about the structure of help provided at the school as it's quite interesting. I really enjoyed my time at Don, thanks :)

Thanks for the opportunity to sit in at the Don College Clinic, it was a good way to see a pocket of individuals in an age range that we don't usually get to see too much of in other healthcare settings. Nice to hear Jane's stance on the importance of adolescent health as it does contribute greatly in regards to a person's future health outcomes, so focusing on what is happening now with this age range is vital and giving them the accessibility to a service that they feel comfortable with is great. Thanks again.

Thank you Emma and Jasmine for your feedback. I will endeavour to see what other events are occurring on campus on the days of the clinic.
I have also modified the whole school focus power point with a presenter component so that it has more meaning for you .
Jane

Thank you again Jane for the teaching, it was a really interesting day. As I mentioned before (and at the risk of repeating myself ad nauseam!) I've been wondering still about how to manage consultations with individuals with borderline personality disorder. I really feel like it's something we haven't been taught how to handle - other than being assured that it's difficult! I guess I was wondering if it were possible to unintentionally normalize or reward self-harming behaviors in the way those issues were discussed in the consultation. I appreciate how important it is to encourage honest answering from patients, and how divulging that information in a non-judgemental environment might even build rapport, but I was just wondering how you felt about that.

Thank you Shannon for your comment. I have provided some articles that you might find useful in response to your questions.
Firstly in relation to self harm itself, this link to REACHOUT.COM might be useful background.
http://us.reachout.com/facts/factsheet/deliberate-self-harm
I have found many young people are ashamed to discuss their self harm behaviour, so some reassurance that it is a common coping strategy is a fair comment to make, but emphasising that it is not the best option and the link above offers some great alternatives to discuss with young people.
Your question in the context of borderline personality is challenging. The first step is to confirm the presence of borderline personality traits vs adolescence in the patients that I see in the the clinic. As young people progress through adolescence some of the 'BPD traits' will settle as the frontal lobe develops and matures. But then for whatever reason as the person near the ends of adolescence these traits still persist with intensity then your approach might change. I agree a true BPD state will perceive self harm as a way to seek attention be that in the form of clinical care. These cases are complicated and to be honest it will only be through exposure and experience will you begin to understand what is BPD , how it will present and how sutle this might be. I think with experience you will begin to guage just what you are dealing with and how safe the patient is from themselves. This is an interesting study , that you might find a useful read: https://bpded.biomedcentral.com/articles/10.1186/2051-6673-1-14
I hope that this assist you . I am happy to talk further with you ,face to face if that would help.
Jane

Thanks again Jane, it was a really interesting placement. As I'm sure most of you are aware, the recent Netflix show 13 reasons why has sparked some controversy on social media and in the mainstream media lately. For those that aren't aware/haven't seen it, the basic premise of the show is that a high school girl has recently committed suicide, and she has left behind a series of audio tapes/cassettes. Each tape is about a specific person, and how they have contributed to her suicide.
There has been quite a lot of backlash, including from organisations like Headspace, saying that the show is glorifying suicide.
When I watched the show, I must say that isn't really the impression I took away from it. My immediate impression was that it did a good job of showing the cumulative effect negative experiences and comments can have on a person.
After sitting in with Jane and listening to the students I can definitely see how some people, especially the ones who are already in a very dark place, might take the wrong message away from a show like this.
I would be interested to hear anyones opinion.

Thanks Hamish. I havent had a chance to watch this as yet, but I would be interested in feedback from others. I was grateful for Hamish pointing this out to me, and I have since spoken to CAMHS psychiatrist , who was also unaware. This reiterates the important place of your presence in our team. As medical students you bring a wealth of different knowledge and exposure that I see as very valuable.

I had a really great experience at the Don College clinic with Jane. I’m very grateful to the students who let me sit in, even when discussing really personal and difficult issues.

Several patients we saw expressed suicidal thoughts. At this stage, I do not feel very competent in managing this kind of presentation. I thought it might be useful to learn more about the immediate management of suicidal adolescents as I think this is a very important skill for us all to have.

For context: adolescents have more suicidal thoughts and behaviours than adults. Suicide is the 3rd leading cause of death for young people ages 10-24 and accounts for 20% of all deaths annually.
Nearly all adolescents who are suicidal have a mental illness (usually depression).
Girls attempt suicide more frequently than boys, but boys are more likely to die from suicide.

Immediate management:
1 Assess risk: low, medium or high.
Risk factors:
= Demographic (e.g. male, older, non-heterosexual orientation)
= Clinical (e.g. previous attempt, family history of suicide, history of abuse/trauma)
= Family/environment (access to lethal means, parental mental illness, life stressors, indigenous)
= Mental state (impulsivity, intoxication, suicidal thoughts especially is pervasive and involves planning).
2. Assess mental state.
3. Consider involving parents if possible.
4. Offer education about suicide risk and underlying mental health condition.
5. Consider the need for hospitalisation.
6. Consider the need for other health professionals or services (e.g. school counsellor, private psychologist, crisis assessment team).
7. Develop a safety plan.
8. Consider psychological therapy or medication to treat underlying illness.
9. Document the risk assessment, mental state, safety plan, and people contacted.
10. Arrange review.

I hope this helps!

Sorry forgot to add my references!
https://www.apa.org/about/governance/president/suicidal-behavior-adolescents.pdf

http://www.racgp.org.au/afp/2014/june/suicidal-adolescents/

Thank you for this summary. I am really impressed at you taking time to seek information to fill a void in your knowledge. One thing that is important to remember that for sometime in your careers you will have back up and support. If you get in too deep, stop and take a breath , and ask for help. Even if during a consultation if things are getting tricky and you are distressed , take a moment and seek help and support. There will come a time in your careers where you will have to manage difficult cases and difficult people, but you will gain skills and competence in this. It does not happen overnight it takes years. It takes 10 000 hours to learn something and become competent. Much of the work I do with young people , had I done this earlier in my career, it would have been challenging and i may have walked away, but with time you can learn skills that you can apply on the run and be able to manage anything. Medicine is a journey, reflection is crucial and learning from your experiences is invaluable. The purpose of the reflective activity is to take time and have you all think at a deeper level outside of the assessment processes that often influence your learning and the degree to which you will apply yourself.

The take home message to managing suicide is to listen, show an interest and if you are not sure call everyone and get everyone involved and document, document , document. When I first started at the college in 2013 I wanted to shut the on campus clinic , it was too hard, too confronting. But I have a team on campus , that helps me shoulder the load that comes with young people in distress. You cant do it all by yourself.
Thank you Freya for providing an opportunity to have this discussion.
Jane

As this placement was intended for, I saw several young people during my day at Don clinic with mental health issues and complex social situations who were kind enough to let me sit in on the consultations. This included foster children with mental health issues and such a convoluted family situation I barely had the facts after two consultations, young people with anxiety and depression as seemingly unrelated comorbidities to their presentation, as well as those who's mental illness may be the underlying cause/contributor to a seemingly organic presentation. As you can imagine, these were not the kind of consultations that I felt like I could run myself now or in the near future. Something that Jane emphasized to me several times throughout the day was not to be discouraged or feel overwhelmed - that these challenging consultations can often shake the confidence of young practitioners, and that she has been in our shoes and wants us to remember that we will all become capable in these areas, but in the beginning the most important thing to remember is safety netting, for you and the patient.
Thank you again Jane for taking the time during the busy day to have those discussions with me.

Thank you Abbey, yes young people in ' state care' pose many challenges for the clinician, although the central/collaborative role of primary care , is a great opportunity to work with services to ensure good communication is in place and where possible the health care /educational team remain consistent when so many other things in their lives are fragmented. These children often have neuro-development issues and so behaviour and overall well being are below average. These consultations can often take time and sometimes the main goal is to achieve rapport and establish a relationship of trust. A big challenge for young people who do not trust anyone , especially the system. The long term sequelae of course is poor literacy and poor long term health outcomes. This is a very good example where early intervention can potentially alter the long term outcomes for these young people .

Thanks again so much Jane for the opportunity for a day in your practise, it was one of the most enjoyable days of my University year so far! I've sat in with a few GPs so far and I think I connected with your style of consultation the most. I really enjoyed talking to you about how you bring up suicide, something that is challenging for all of us. I like how you 'just asked the question', didn't beat around the bush and just asked it casually as if you were asking if they had any allergies! I think it really made a comfortable platform for the students to answer you truthfully. We have had some clinicians in the past teach us to sign post it a lot more (obviously every case is different) and i think that can often make it more uncomfortable for the student!

Something else I really took away was your use of safety netting. I feel that even though the consults were short, every patient went away with a strong idea of their management plan, felt empowered and knew what to do if they started feeling bad/knew where to get help.

I feel you did an amazing job at knowing when the reason that someone came to visit you want the reason they told you in the first 2 mins!! This really reinforced the importance for me to run through a quick heads or similar for many patients (or just asking how things are/whats been happening) as you more often than not find something underlying their initial presentation!!!

Thanks again for your time! I feel ive learnt a lot!!

That is excellent feedback thank you. My concern for all of you is that this is primarily a clinic where patient needs are paramount and a teaching learning environment second. On these busy days I am always concerned about how much you might learn and take away. This reassures me that even in that busy intense practice you are still able to gather gems of learning.

I think that this day we spend at Don College is so valuable for our rotation in Psychiatry. Thank you Jane for allowing us to sit in on your consultations. I'm also so grateful to all those young people who let me listen while they shared some very difficult stories. Seeing such young people dealing with such tough situations was very eye opening for me. So many of these young people have dealt with such difficult social backgrounds and difficult personal problems. Jane, your discussion with me about how important it is to take care of yourself when you're hearing so many painful stories really struck a cord with me. It was helpful for me to hear that caring about your patients and feeling personally unsettled is not a bad thing and can continue to happen even as an experienced clinician. It can be quite overwhelming as a student and sometimes it feels like we need to always keep our guard up. Jane, you made a comment to one of the patients that really stayed with me. You said that they have so much resilience, much more resilience than anyone else her age. It was almost like the silver lining. This young girl had gone through so much but those experiences had made her so much stronger. I thought a lot about that later on and it was just a nice thought to take away amongst everything else.

thank you Kavita. Medicine is a very challenging vocation , when you consider the things that people might tell us. From my own personal successes and failures in self care it is paramount that you watch out for yourself. You can be no good to anyone if you yourself are not dealing or acknowledging your own shortcomings but also not forgetting about your strengths . Sometimes just being able to say 'no' can very empowering and it can take many years as a clinician to develop such a simple skill. Take care all of you, you have such a great deal to bring to the world of medicine in your own futures. Jane

Jane, watching you work and talking with you was one of the days in med school that reminds you why you're there. I have always been interested in chronic disease prevention and mental health. The way you described your professional journey to becoming an adolescent health professional has shaken up my perception on chronic health. Managing those sociocultural contributors, forming healthy habits early on, and tackling incredibly difficult home/life situations in these young people not only makes a difference to their lives now, but just might be the difference for our future general practice and the patients that my colleagues and I might be seeing in 20 years time.

Watching you talk to these young people in such a relaxed, but also straight-up manner was very refreshing. I think that in medicine, the importance of professionalism sometimes becomes misconstrued to mean valuing rigid-thinking and stoicism. Whilst I am not advocating for becoming overly emotional (or even overly empathic) with our patients, I think that it is helpful to remember that sometimes, professionalism can mean using the jargon that the teenage patient in the room uses to make them feel more comfortable, or making a joke about speculums to ease the tension.

Speaking of tension, we had a chat on the day about the current media coverage of mental health within the medical field and of SBS's Insight program - "Critical Care". The forum is well worth a watch for us medical students as a wake-up call that most of us have (or will have) periods of difficulty in what is a demanding profession. It also clarified for me the details of 'mandatory reporting' and the situations in which it does and doesn't apply. For example, for most mental health problems that a doctor might be experiencing (namely depression and anxiety), these do not fall under the category of being mandatorily reportable. Talking more freely about the challenges we face, or may face in the future will hopefully instigate some top-down reform which provides doctors the working conditions to be the best doctors they can be, as well as some grass-roots cultural change within the field. The link to the program is here for those of you who are interested: https://www.sbs.com.au/ondemand/program/insight

Thank you Grace. No matter how much experience and expertise you have you are not immune to the stressors of medicine. This is a wonderful vocation, and can take you to great places on many levels. But it is demanding and at times unrelenting and there can be nothing but negative feedback or experiences. But one positive comment can be life saving. As health professionals we are not always good at checking on each other or giving ourselves a pat on the back. I would encourage all of you to remember to check in with yourselves and your peers and start to bring about the change in our profession that is needed to keep us all safe and well and functioning as good doctors in communities that desperately needed our services.

It was nice to head back to Don and see such a great service being provided. It was also great to see a completely different demographic to what we see on our GP rotation. Observing how you approach an adolescent history was very insightful and has definitely given me better insight into how id approach one, particularly how I’d ask some of the more sensitive questions such as suicidality.

It was also interesting to see how important it is the do a HEADSS risk assessment even if they present for something very straight forward. It can be easy to go down a single path and not explore other aspect. Today gave me a great example of how effective a quick HEADSS assessment can be.

Thanks for a great day!

I thoroughly enjoyed this day at Don College. It was insightful to what life is like these days as an adolescent, and the main things that they seem to be struggling with. Jane you showed me the integral of a GP in a community like this. Showing the importance of the therapy of just 'talking it out' about something that is big in their lives right now rather than only coming to see you when something medical is wrong, and how beneficial it can be for them.
I also had the pleasure of meeting Claire, a social worker who identifies as Queer and works for an organisation call "Working it out". WIO are an organisation who provide a support and educational service for Lesbian, Gay, Bisexual, Transgender and Intersex people and their families across Tasmania. It was pretty amazing to hear some of the great things going on, and support networks there are for young people who are struggling to find themselves.
Once again, thank you Jane for a great day at the Don.

P.S Here is a link to WIO: http://www.workingitout.org.au

Thank you both Alex and Luke for your comments. I think both of you saw the benefit of the HEADSSS assessment in clinical practice. The more you do it the better you may get at quickly running through this. I think it is a very fluid thing and does need to be addressed every couple of months. IT would be good to see a Medicare item number for an annual health assessment for young people that incorporates a HEADSSS and have it reviewed every year. Things can change quickly for young people.
It was good timing Luke to meet with Claire. Working It Out is a fabulous service.
Jane

I had a really lovely day at Don Clinic, I think like many others it was such a good change to see this demographic when the opportunities to do so are otherwise pretty limited. I was so impressed to see the implementation of a new anonymous chlamydia screening program, which provides students with urine sample bottles and an anonymous collection bin. It's amazing to see health disparities met with such innovative action.

One of the other interesting points I took away was our discussion around the ongoing social and health issues that a large proportion of the ATSI population faces. I wondered about the part that epigenetics plays in this, but unfortunately there doesn't seem to be much existing research into the area. I'll be interested to see what happens!

Thank you Dariel , I think you raise some interesting questions around epigenetics. And the online chlamydia screening has just started so that too is a watch this space. It highlights the place of making health care as accessible as we can.

Thank you Jane for a fabulous insight and learning day at Don College medical.

Some important learning and reflection points from the day included;
- Realising what the term "adolescent-friendly" medical practice truly means. It was interesting to compare the Don clinic with other general practices I have been in and realise that adolescents are not confronted at all by DIY Chlamydia testing whilst you wait, or large posters about sexuality.

- I was also humbled by the honesty of young people and can appreciate that they are expecting you to ask the hard, personal questions. Hopefully I can incorporate this into my future practice.

- Lastly, I guess being lucky enough to have grown up in a stable home has sheltered me from the impact of unstable family and housing dynamics. We saw a young male who had been "couch surfing" for months and yet didn't consider himself as homelessness. It was interesting for me to discover that in many cases, these patients actually do better if they can find independent accommodation for themselves.

Thank you again for sharing your story, style and advice. It was a great day.

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