Abstract
We are foreign trained psychiatrists. We came to New Zealand for adventure, to learn about a new culture, to expand our horizons and to practise our craft: psychiatry. We come from different countries of origin, the first author from the USA and the second from India. We signed up for a year, but one of us (TS) is leaving after 8 months and the other (SK) has stayed for 6 years. These differences notwithstanding, many of our experiences have been quite similar. We have accomplished our goals. We have found New Zealand to be a stunning country with an incredibly rich culture. We have also found it to be a country that is failing its people: those who most need help, those least able to advocate for themselves, those with mental illnesses.
Marginalization of mentally ill people is not unusual in the world today. It certainly isn't unusual in the USA or India. However, as psychiatrists in New Zealand, many of us have been unwitting accomplices to this phenomenon by our coming and going. According to the Medical Council of New Zealand workforce survey of 2000, the number of new overseas-trained doctors registering permanently in New Zealand during the previous 3 years decreased by 50% compared with the 3 year period prior to 1995.[1] However, the proportion of overseas-trained doctors working in New Zealand had increased in 2000 compared with 1995.[1] In other words, many doctors are attracted to work in New Zealand but very few stay. Furthermore, the number of psychiatrists in New Zealand as a whole seems to be shrinking. A recent publication from the Clinical Training Agency (CTA), the official body that manages postgraduate training in New Zealand, indicated that the number of qualified psychiatrists practising in New Zealand was decreasing.[2] Based on New Zealand Medical Council's Annual Workforce Survey of March 2000, there were 274 psychiatrists working in New Zealand as of March 2000, making a ratio of approximately one psychiatrist for every 14 000 people. Compare that with the March 2002 data of 261 psychiatrists who held current Annual Practising Certificates, giving a ratio of one psychiatrist for every 15 000 people. In comparison to the World Health Organization (WHO) recommendation of one psychiatrist for a population of 10 000,[3] there was a workforce deficit of approximately 128 qualified psychiatrists in 2000.[2] The country has no alternative other than relying on overseas-trained psychiatrists to deliver mental health services to its people. Foreign trained psychiatrists come to New Zealand but they do not stay. As psychiatrists who have participated in this sad ebb and flow, we would like to examine why psychiatrists do not stay in New Zealand. We propose to describe why psychiatrists come and go from New Zealand from the perspective of the expatriate, and to speculate about the effect of that transience on our patients.
The CTA attributes the shrinking number of psychiatrists to attrition related to retirement and local graduates finding employment overseas. We beg to differ. Although retirement and emigration of local graduates may play a role, we believe there are systemic issues that require examination. We propose to speak for the practice of psychiatry, and we propose to speak on behalf of our patients. And make no mistake, they are our patients. We claim them and they claim us as their doctors. As we describe below, that is the crux of the problem. There exists a schism between administrators who recruit psychiatrists and those of us who are the fruits of their labour. The effects of this schism, we believe, explain why psychiatrists find it difficult to stay in New Zealand.
A word about the practice of medicine, the practice of psychiatry. Doctors tend to be passionate about their profession. We tend to be optimistic and we tend to believe that we can make a difference in the lives or our patients, our communities and our world. We spend many long years in training and many more years in practice. The years in training teach us to think like physicians, like scientists. The years in practice teach us to be artists. The paint, the brush and the technique we learn at the hands of our elders. The creativity, the imagination, the passion and compassion we are born with and we fine-tune on our own. Our art is an expression of our deepest selves. We are indeed technicians of our trade. But, much more importantly, we are artists expressing ourselves through our tools.
Administrators come to their work with a different set of purposes and passions. Administrators are interested in financial matters and in protecting organizations from economic adversity. Shortell has identified seven attributes differentiating doctors from managers: our knowledge is derived from biomedical sciences; we have wide exposure to many health-care disciplines but little to business and economic aspects of health care; we have a narrow rather than broad patient focus; we have a short time frame for action; our rules for evidence are based on tightly linked causal relationships; we have a perception of limited resources; and we have a cohesive, highly developed sense of professional identity.[4] These attributes make us two totally different groups of people. Lazarus has suggested that the two groups have different psychological dispositions: psychiatrists tend to be introverted, feeling and perceiving, while administrators tend to be extroverted, thinking and judging.[5] We are very different people who are bound to have different perceptions and priorities. And, to a certain extent, a dynamic tension needs to exist between us for the overall benefit of our common purposes and our patients’ welfare.
With the chronic shortage of psychiatrists, the country has relied on locums. However, the administrative mindset upon hiring a locum consultant psychiatrist seems to be that a technician has been hired who will manage medications for patients. We believe this mindset creates an untenable work situation for physician and patient. The physician is treated as a commodity to be used and patients are channelled among the commodities to be ‘managed’. The result of this attitude is a dangerous work environment for the physician and, at best, a modestly satisfactory dabble in the patient's medications.
How is the work environment dangerous for the physician and how does a dangerous work environment translate into poor patient care and poor patient outcomes? Study after study has demonstrated that the relationship between patient and physician is the single most important factor in determining favourable patient outcomes. Any clinical or administrative practice that disrupts this relationship affects quality of care and subsequent patient outcomes. Yet continuity and quality are forever being disrupted by reactionary administrative policies that: (i) fail to recognize that when a physician sees a patient, the patient's mental health welfare becomes that physician's responsibility and liability, which cannot simply be shuttled to another physician; (ii) do not acknowledge that the amount of time spent with each patient is a clinical decision that impacts upon the physician-patient relationship, quality of care and patient outcomes; (iii) believe that ‘all comers’ must be accepted and treated regardless of the capacity of the physicians to take on more patients; this stretches physicians so thin that they cannot provide minimum quality of care for current patients (e.g. have no room to schedule return visits in 2 weeks or 1 month even though the patient may be on a complicated regimen of medications that would normally demand close monitoring); (iv) fail to provide even the minimum essential work environment: pens, paper, warm office space, computer access; and (v) seemingly make things as difficult as possible instead of supporting these critical staff (indeed often adopting a bullying stance toward physicians and the clinical practice of medicine).
Clearly, we have found that the work environment exacerbates our already high liability, interferes with our ability to practise good medicine, and compromises our ability to achieve good outcomes with our patients. We know that relapse rates in mental illness are high. We know that in spite of years of public education, social stigma around mental illness remains a major problem. Although practising psychiatry in New Zealand is difficult, being a mental health patient in New Zealand must be close to impossible. Unfortunately, our patients do not have any choice about that. Although we find the system to be damaged, we do not believe it to be broken beyond repair. Efforts at recruiting psychiatrists are effective, but retention is poor.
From our perspective and from discussions with other expatriate psychiatrists, we have found the work environment to be hostile, caseloads to be ridiculously high, subsequent liability to be huge, physicians to burn out quickly, and patients to receive only marginal care from a system that fails on many fronts. Clark and Vaccaro, nearly two decades ago, identified similar factors contributing to job dissatisfaction in psychiatrists.[6] A lack of administrative support and validation, low pay, responsibility without authority, and pressure to sign documents related to patients unknown to them, were related to job dissatisfaction. We have found all these factors rampant in New Zealand, especially in small rural centres. Attitude makes all the difference. Using people as a means to an end never works. Because New Zealand must depend on locum consultants for the foreseeable future, the only alternative is to engage our colleagues in a common goal of providing high-quality care for those who need it most. We ask to be engaged by our administrative colleagues. We ask for a change of mindset. We all stand to gain from a collegial relationship. Most importantly, our patients’ mental health is at stake. Let us use our best collective resources and our most productive attitudes to create a healthy mental health system.