Professor John Watson
Sydney Adventist Hospital Clinical School
Clinical Education Centre (Building 23)
185 Fox Valley Road
Wahroonga NSW 20756
Mental Health Commission of NSW Submission to Sydney Medical School Curriculum Update and
Redesign
Dear Professor Watson
Thank you for your letter of October 14 and for the opportunity to comment on the update and
redesign of the University of Sydney Medical School curriculum. I would like to offer a view of how a
mental health perspective might be fully integrated into your students’ learning.
As you are aware, the history of mental health treatment in NSW, Australia and internationally, has
been very difficult and sometimes traumatic. A legacy of inhumane practices, some of which
continue today, has fostered a degree of mistrust between the psychiatry profession and mental
health consumer advocates. This plays out in dichotomous rhetoric around a “medical model” of
mental health, which posits the doctor as the central decision-maker, versus the person-centred
notion of recovery – in which the individual seeks support and chooses from available services which
may or may not include medical treatment. In fact, good medical practice is entirely compatible with
a consumer-centred approach that honours the human rights of people who live with mental illness,
and I believe medical education should emphasise this.
The national framework for recovery-oriented mental health services: guide for practitioners and
providers i is essential reading in this respect, and I would certainly suggest that you draw upon it to
develop curriculum resources. Medical students need to be aware of the nuances of mental health
recovery as a process led by the individual, and develop their own understanding of how they can
use their medical skills – and sometimes medication – to support people with a mental illness, in a
way that respects the person’s autonomy. They should always listen closely and value the person’s
expertise in their own situation. The Commission’s publication Perspectives: Medications and Mental
Illness, and related videos, may be helpful resources in this regard. ii iii Importantly, the goal of
recovery may not be freedom from symptoms. The Butterfly Foundation’s Insights in Recovery: A
consumer-informed guide for health practitioners working with people with eating disorders iv,
produced with funding from the Commission, similarly presents to doctors how recovery-oriented
practice can operate in this complex area. It could be used to support medical education, for
students or later in a doctor’s career.
At the same time I would urge you to ensure all medical students become trauma-informed. The
eminent psychiatrist Professor Louise Newman has described the failure to acknowledge trauma as
“one of the most significant clinical and moral deficits of current mental health approaches.” v
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Psychological trauma, particularly in childhood but at any time of life, can have enormous
consequences for people’s mental and physical health. Understanding someone’s story, and
appreciating at a profound level that current “problematic” behaviour may be a direct consequence
of their experiences, is an essential first step to supporting them effectively according to recovery
principles.
Mental distress – whether or not it meets diagnostic criteria – has an enormous influence on a
person’s life and their health. Australian GPs manage a psychological problem in one in every seven
patient encounters, though this may not be the ostensible reason for the patient’s appointment. vi
All doctors need to be open to understanding the complexities of people’s lives, and how
psychological distress can be either a cause or a consequence of social challenges such as
relationship issues, problems at work and – particularly – poverty with its related issues of food and
housing insecurity. Additionally, as described during a recent visit to Sydney by Sir Harry Burns,
Scotland’s former chief health officer, the great majority of excess premature death among men in
that country is concentrated among those who are young or in earlier middle age, and its causes are
principally suicide, drug and alcohol use, accidents and violence vii – all of which are at least
potentially mediated by mental health problems. Cancer, stroke and heart disease by contrast
contribute relatively much less to the excess death rate. (A comparable analysis has not to my
knowledge been completed in Australia).
A strong public health/social determinants of health perspective across all elements of the medical
school curriculum – including those related to body systems and disease – will ensure doctors learn
to appreciate the context in which people’s health problems arise, which in turn will make them
more effective in responding to them. Mental health is deeply interwoven with all these issues, and
should never be overlooked or minimised.
Related to this, all doctors should have an understanding of the Aboriginal concept of social and
emotional wellbeing, “a multidimensional concept of health that includes mental health, but which
also encompasses domains of health and wellbeing such as connection to land or ‘country’, culture,
spirituality, ancestry, family, and community”. viii This is essential understanding as doctors work to
respond appropriately to the mental or physical health needs of Indigenous patients. In addition, the
framing of social and emotional wellbeing encompasses important values that I believe can speak to
the whole community. Certainly they anchor the work of this Commission.
Most doctors aspire to move well beyond “first do no harm” to a place where they are doing active
good, and that frequently includes speaking up for a patient or group of patients. Advocacy skills
therefore are essential tools alongside clinical skills and I would like to see an advocacy focus
integrated into student learning – including for the needs of individual patients but also in systemic
advocacy that can highlight injustices, inefficiencies and other failings in the health system. The
Australian Medical Association articulates this well in its position statement on the role of doctors.
Doctors are community leaders and, “their role of advocacy for patients, communities and
particularly for patients and communities who may be disenfranchised or powerless, is vital in
contributing to improving health and wellbeing outcomes.” ix These issues apply particularly forcefully
in our current mental health system, which has been systemically under-funded in relation to the
burden of disease attributable to mental illness. x
None of the matters I have discussed relate to clinical knowledge. The Commission greatly values the
sincere commitment of psychiatrists, general practitioners, and other doctors to respond with
appropriate clinical approaches to people who experience mental illness, as well as those who work
to develop the research evidence base. However we do not have the necessary expertise to
comment on the appropriate content and staging of the medical school curriculum in this respect.
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The Commission’s interest, as established in the Mental Health Commission Act 2012, is to “monitor,
review and improve the mental health system and the mental health and wellbeing of the people of
NSW.” xi This is the driving force behind Living Well: A Strategic Plan for Mental Health in NSW 20142024 xii, which is derived from the perspectives and orientations I have described and is now NSW
Government policy. I believe that if the University of Sydney embeds these principles across its entire
medical curriculum it will produce doctors who are excellently equipped not only to respond to
mental illness but to the complex human needs of all patients.
I look forward to learning how the University takes this important initiative forward, and would be
happy to offer any additional input you may require.
Warm regards
John Feneley
1 December 2016
i
Australian Health Ministers’ Advisory Council, national framework for recovery-oriented mental health
services: guide for practitioners and providers, 2013
http://www.health.gov.au/internet/main/publishing.nsf/content/67D17065514CF8E8CA257C1D00017A90/$Fil
e/recovgde.pdf
ii
Mental Health Commission of NSW, Perspectives: Medications and Mental Illness, 2015
http://nswmentalhealthcommission.com.au/sites/default/files/publicationdocuments/Medication%20and%20mental%20illness%20perspectives%20-%2012%20Feb%202016.pdf
iii
https://www.youtube.com/playlist?list=PLmdoKIibCmXZDX18G1WkZGb2VGMiBCvGu
iv
Butterfly Foundation, Insights in Recovery: A consumer-informed guide for health practitioners working with
people with eating disorders, 2016
https://thebutterflyfoundation.org.au/assets/Uploads/ButtInsights-BOOK1-online-nov5-FINAL-20161107.pdf
v
Mental health Coordinating Council, Trauma-informed Care and Practice: A National Strategic Direction, 2013
http://www.mhcc.org.au/media/32045/ticp_awg_position_paper__v_44_final___07_11_13.pdf
vi
Family Medicine Research Centre, University of Sydney, General Practice activity in Australia 2013-14, 2014
https://ses.library.usyd.edu.au/bitstream/2123/11882/4/9781743324226_ONLINE.pdf
vii
The Scottish Government, presentation (p30), 2016
http://rcpsc.medical.org/publicpolicy/documents/2008/DR_HARRY_BURNS.pdf
viii
Commonwealth of Australia, Working Together: Aboriginal and Torres Strait Islander Mental Health and
Wellbeing Principles and Practice, 2014
http://aboriginal.telethonkids.org.au/media/699863/Working-Together-Book.pdf
ix
Australian Medical Association, Role of the Doctor Position Statement, 2014
https://ama.com.au/system/tdf/documents/Role_of_the_Doctor_Position_Statement_2011_0.pdf?file=1&typ
e=node&id=40675
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x
Mental Health Commission of NSW, Living Well: Putting People at the Centre of Mental Health Reform in
NSW: A Report, 2014
http://nswmentalhealthcommission.com.au/sites/default/files/publication-documents/Living%20Well%20%20Putting%20people%20at%20the%20centre%20of%20mental%20health%20reform%20%20A%20Report_0.pdf
xi
NSW Parliament, Mental Health Commission Act, 2012
http://www.legislation.nsw.gov.au/acts/2012-13.pdf
xii
Mental Health Commission of NSW, Living Well: A Strategic Plan for Mental Health in NSW 2014-2024, 2014
http://nswmentalhealthcommission.com.au/sites/default/files/141002%20Living%20Well%20%20A%20Strategic%20Plan%20(1).pdf
Locked Bag 5013
Gladesville NSW 1675
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T 02 9859 5200
F 02 9859 5251
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E [email protected] | TD16/10548
W www.nswmentalhealthcommission.com.au
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