Fellowship in Forensic Psychiatry

As most readers will be aware, the specialty qualification for psychiatry in Australia and New Zealand is overseen by the Royal Australian and New Zealand College of Psychiatrists. The College was formed in 1946 as the Australasian Association of Psychiatrists and has its headquarters in Melbourne. Entry to the training programme is restricted to Registered Medical Practitioners, usually in the third or subsequent year after graduation from medical school. Most trainees are required to have had at least one year's experience working in psychiatry prior to admission into training. The training programme provides for ongoing assessment throughout the first three years and trainees are eligible to sit the Part I examinations after fulfilling the obligations of the first 36 months of training. After completion of 48 months training and successful negotiation of the Part I exams, trainees are required to undertake a further 12 months of training and complete a dissertation, constituting the Part II examination. There is provision for trainees to undertake the 5th year of training outside Australia and New Zealand, however only a handful of candidates have done so.

During my medical career, prior to entering the psychiatric training programme, I had worked in Australia, New Zealand, England and the Bahamas. I felt that working in different environments had broadened my perspective in a general sense and specifically in terms of my medical experience. Thus, it was quite natural for me to consider that I would benefit, personally and professionally, if I were able to arrange to undertake my 5th year training in a different environment and health care system. It is quite common, if not the norm, for senior registrars and junior consultants in surgical and medical specialties to undertake part of their training overseas, especially by working in the United Kingdom or United States. They utilize the opportunity to learn new techniques and take part in research programmes. It was with those aims in mind that I set out to organize an overseas placement.

Having already established that I would pursue a career in Forensic Psychiatry, I made my initial investigations towards the end of my 3rd year of training by looking through international journals to get names and addresses of figures in the United Kingdom. An internet search provided more useful information and I initiated correspondence with some English institutions. I then sought the advice of senior figures in the field in Melbourne. It was important for me to make contact with these senior clinicians because they had the knowledge of local and overseas systems which I could not readily access by less personal means. It became clear, however, that I would not be in a position to get a senior registrar position in the UK prior to gaining my FRANZCP. A UK registrar position would not provide the level of responsibility and experience which I was seeking and would not be equivalent to the seniority of a 5th year trainee position in Australasia. I then performed a second, and broader, internet search, which included the United States. It was the result of that search which provided me with information on the Forensic Fellowship placements throughout the United States and Canada. For Australian and New Zealand medical graduates, it is not an easy task to gain a work visa in the United States so I focussed my enquiries on Canada and ultimately obtained a position at the Forensic Division of the Department of Psychiatry at the Calgary General Hospital. Apart from the referees' reports, all correspondence occurred via email.

My initial contact with Calgary occurred in the middle of my 4th year and I then had to negotiate approval for the 5th year attachment with my regional Director of Training and fulfil the appropriate immigration requirements of the Canadian authorities. The latter was not an easy task and required terrier-like persistence. Conversely, the College and Director of Training encouraged me and provided no obstacles to my plans at any stage.

Upon my arrival in Calgary, there were several logistical difficulties to be overcome. As the maximum daily temperatures at the time were −5 degrees, purchasing appropriate clothing was a high priority. Then I had to find a school for my daughter and find accommodation in a city with a rental property vacancy rate of 0.5%. As I had arranged an appointment with the Registrar of the College of Physicians and Surgeons prior to leaving Australia I was able to be registered on my first day in Calgary but then had to negotiate accreditation with the hospital (a clerical oversight in the hospital) and medical protection coverage. These were little problems indeed compared with the difficulty I had in obtaining insurance for the motor vehicle I leased. ‘You mean you drive on the WRONG side of the road in Australia?’

The easy part of my translocation was slipping into the work environment in Calgary. Australian and New Zealand health professionals enjoy an excellent reputation in every country in which I have worked and Canada is no exception. A fellowship, in the North American context, is a 1 or 2 year period, usually following the Residency (registrar) training, where a junior consultant engages in subspecialty training. The subspecialty training in Forensic Psychiatry is formalized in the United States, with a Board examination, conferring a subspecialty qualification. As in Australasia., no such equivalent qualification exists in Canada.

The Fellow works much as a Senior Registrar, having a leadership role within the multidisciplinary team, while being overseen and supervised, at arm's length, by the Unit Director of Psychiatry. The position, however, is seen very much as an educational one. In fact, this is explicit in the form of registration with the College of Physicians and Surgeons, with which I was enrolled on the Educational Register, with no right of private practice or ‘moonlighting’, which refers to undertaking additional paid duties within or outside the hospital. The Fellow is enrolled at university, in my case at the University of Calgary, and receives regular tuition, supervision and prescribed reading. In addition, the Fellow is expected to undertake a research project, leading to publication. Because the role is seen as an educational one, the service provision aspect of the job is less than that expected of a senior registrar in the Australasian context.

I spent the first six months working on the forensic inpatient unit, with a patient load of five or six, attending the Provincial Court to perform triage fitness to stand trial assessments, attending a Medicine and Law course at the University and planning a research project. In the latter half of the year I undertook and wrote up the research project and spent 3 months each working on the Forensic Adult and Adolescent Outpatient Services, in addition to the court triage work. The outpatient work was office-based and also involved opportunities at the local Young Offenders Centre, Remand Centre and Prison.

I arrived at a time of flux within the department. The city's hospitals had recently been regionalized, the department had recently moved from downtown to an outer suburban location and the Director of the Forensic Division resigned during the year. In the context of the upheaval associated with these events, I had the opportunity to observe the effects on the service and team morale. It was interesting for me to compare the way similar events had occurred when ‘networking’ occurred in Melbourne in the mid-1990s. In both cases, it appeared that decisions made at a political level were foisted upon a dissatisfied workforce, resulting initially in personal upheaval, low morale, disintegration of patient services and bed shortages. Strangely, and somewhat morbidly, in both instances, police shootings of psychiatric patients in the community occurred contemporaneously. The Calgary Herald headlines so mimicked the Herald Sun headlines that I sometimes thought that I had not left Melbourne.

Being located in North America, I was able to attend the American Psychiatric Association Annual Conference in Toronto and the Annual Meeting of the American Academy of Psychiatry and the Law in New Orleans, without too much difficulty.

As I had completed my Dissertation during my 4th year, I did not have time pressures to write up my research project to minor thesis standard, but would easily have managed to do so if I had been required, due to the user-friendly structure of the Fellowship. The Fellowship offered me the opportunity to work within a different health system, a different legal system, attend international conferences, take part in a formal education programme and generally broaden my outlook.

Historically, medical graduates from Australia and New Zealand sought overseas training in order to specialize. As local specialty training programmes and qualifications became available, there was no longer the imperative to travel. Nevertheless, graduates of non-psychiatric training programmes often venture overseas and there is much to be gained from working in a different environment. Financial and personal sacrifices are inevitable if one is to travel overseas for an extended period, but the personal and professional rewards outweigh the costs.

In my case, I have made invaluable professional contacts and, undoubtedly, lifelong acquaintances and friends. I have great respect for those dedicated few within the College who have crafted a well-balanced training programme which has the breadth of scope to encompass all of the major therapeutic modalities but still has the flexibility to enable trainees to undertake an Elective year in another country. The training is a long, difficult process to go through, but I believe that it successfully fulfils its aim: to provide a depth of training and ethical professionalism worthy of a consultant psychiatrist.

I thoroughly recommend that trainees consider undertaking a Fellowship overseas during the 5th year of training. The professional benefits are significant and your children will love you forever – the skiing in Banff is something else!