Rural workforce challenges: Why not rural psychiatry?

Abstract

Objective

The Australian psychiatry workforce is under-subscribed and highly urbanised. Currently, 90% of psychiatrists work in the cities, and there are significant projected workforce shortages of psychiatrists throughout Australia, particularly in rural and remote locations. This qualitative study explores factors influencing medical students and junior doctors’ decisions to pursue a career in rural psychiatry.

Method

Using a phenomenological approach, data were collected through semi-structured interviews and focus groups and subjected to thematic analysis.

Results

Sixteen participants were interviewed, 11 interviewees and five participants from two focus groups. This study identified enablers and challenges in pursuing rural psychiatry training in Australia. Clinical exposure to rural psychiatry, personal factors, rural lifestyle and workforce shortage awareness were identified as enablers. The lack of rural infrastructure, the attractiveness of urban psychiatry and the stigma toward rural psychiatry were identified as barriers.

Conclusions

Australian rural psychiatry workforce remains a complex issue. Reinforcing enablers and addressing barriers identified in this study would benefit future rural workforce initiatives.

Keywords

psychiatry rural shortage workforce

Psychiatry recruitment has been an ongoing issue both in Australia and internationally. Only 3–5% of medical graduates considered psychiatry their first career choice globally.¹ The lack of quality exposure to clinical psychiatry during medical school and pre-vocational training years and the stigmatisation of psychiatry have been identified as the main factors deterring medical students and junior doctors from pursuing psychiatry.² Furthermore, medical graduates’ decision to find the ‘right fit’ is complex, requiring ongoing personalised career advice, training pathways, tailored support and career development opportunities.³

The Department of Health in Australia projected a future undersupply of 425 psychiatrists by 2025.⁴ The shortage was further exacerbated by the maldistribution of psychiatrists in the rural and remote areas, with almost 9 out of 10 full-time psychiatrists (87.6%) employed in major cities in 2017.^4–6 Meanwhile, Australians living in rural and remote areas generally experience poorer health and welfare outcomes because of their unique risk factors. This includes reduced access to health services, travel distance to a tertiary centre, engaging in high-risk occupations such as farming and environmental factors like flood, bushfire, drought and the COVID-19 pandemic.^5,7 Adverse mental health outcomes, such as suicide rates and self-harm, are significantly higher in rural and remote areas.⁸ This study explores medical students’ and junior doctors’ perceptions and experiences about rural psychiatry training.

Methods

This qualitative study was informed by the principles of phenomenology. We used purposive sampling of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Psychiatry Interest Forum (PIF) members. The RANZCP developed PIF to foster the interest of medical students and pre-vocational doctors in undertaking psychiatry specialist training. Study participants were recruited by email invitation through the PIF email database.

Data were collected through semi-structured online Zoom interviews and focus groups conducted by WD. The interview consisted of open-ended questions based on a current literature review and explored participants’ perspectives on the barriers and enablers to pursuing rural psychiatry. The interviews ranged from 20 to 45 min with an average duration of 30 min. NVivo12 software was used to assist with the thematic analysis of de-identified transcripts.

Results

A total of 16 participants were interviewed between January 2021 and January 2022. Participants' characteristics are listed in Table 1.

Table 1.

Participants' characteristics

Characteristic	Count (n)	Proportion (%)
Gender
Female	9	56
Male	7	44
Stages of training
Medical student	7	44
Post graduate year	9	56
Demographic background
Rural	10	62.5
Metropolitan	6	37.5

Four main themes arose as enablers: clinical exposure to rural psychiatry, personal factors, rural psychiatrists’ lifestyle and workforce shortage awareness. The four main themes identified as barriers were the lack of infrastructure, appeal for urban psychiatry, social isolation and family commitments and stigma towards rural psychiatry. A summary of themes is discussed below, and representative quotes are listed in Table 2.

Table 2.

Participants’ quotations illustrating the themes and sub-themes

Theme	Sub-theme	Supporting verbatim quotations
Enablers	Clinical exposure to rural psychiatry	‘If you train rurally, you get to see how good it is, and that can attract you back’. (P03; male; PGY1)
		‘We have more contact and more access to psychiatrists during my rural rotation’. (P10; male; PGY2)
		‘My experience in rural psychiatry focuses on helping patients in all aspects of their life; it allows you to have so much more time with patients’. (P01; female; PGY1)
		‘The ability to interview patients during my rural rotation is very helpful’. (P10; male; PGY2)
		‘I found that people I encountered in rural psychiatry made a big difference; it’s very rewarding to help people in this capacity’. (P07; male; MD3)
	Personal factors	‘Pursuing rural psychiatry was always my intention in going to medical school’. (P02; female; PGY1)
		‘I grew up in a rural town, so there are a lot of people with psychiatric problems that are unrecognised, and my grandfather had some psychiatric illness’. (P03; male; PGY1)
		‘I want to do psychiatry after being through various mental health things myself, and I want to help people in my rural hometown’. (P05; female; MD2)
		‘We had many farmers with suicides, and I want to help people in rural areas’. (P07; male; MD3)
		‘Being from a rural background, I’m interested in going back rurally depending on what those options would be’. (P07; male; MD3)
	Rural psychiatrists’ lifestyle	‘Rural psychiatry is a pathway that you can do indefinitely, there’s lots of opportunities to move into the regional leadership role’. (FG2; female; PGY2)
		‘Talking to a registrar about the rural pathways and the lifestyle has been very positive and encouraging’. (P03; male; PGY1)
		‘Rural psychiatry offers a good work-life balance, and the shortage means you can get into the program’. (P11; male; MD3)
		‘You don’t have to do as much overtime in rural psychiatry and that makes a huge difference in your lifestyle. Cheaper cost of living and I love the convenience of rural living’. (P10; male; PGY2)
		‘Once you experience the rural lifestyle, it’s not as isolated as people assume it is’. (P08; female; PGY1)
	Workforce shortage awareness	‘First and foremost, rural doctors are under-represented, psychiatrists especially’. (P04; male; MD2)
		‘In rural psychiatry, your ability to make a difference is much greater’. (P10; male; PGY2)
		‘Rural psychiatry training you can almost guarantee that you’ll get through your training because it’s not as bottlenecked like in the city’. (P03; male; PGY1)
Barriers	Lack of rural infrastructure	‘I don’t think there would be psychiatry training available in the country, and that’s the same for most specialties’. (FG2; female; PGY2)
		‘One of the biggest barriers is simply not knowing that it’s an avenue that exists’. (P04; male; MD2)
		‘I think that the rural psychiatry you get exposed to is not very representative of what you could do in the field’. (P09; female; PGY1)
		‘There are more psychiatrists and support structures available in the city’. (P07; male; MD3)
		‘You have a much higher workload because we don’t have as many psychiatry trainees’.(P08; female; PGY1)
		‘The big limitation for me pursuing rural psychiatry is what’s available in the town and the support structure for trainees’. (FG1; female; MD5)
	Appeal for urban psychiatry	‘…but I can get twice as much doing this in the city’. (P05; female; MD2)
		‘I think the weekly training you get in the metropolitan centres is more protected and better structured’. (P03; male; PGY1)
		‘The rural renumeration would have to be higher than psychiatrist in the city to offset the potential loss of income from private practice’. (P03; male; PGY1)
		‘… but in Psychiatry, you are in demand in the city as well, so you don’t have to go rurally’. (P06; male; MD2)
	Social isolation and family commitments	‘It’s mainly for family support, but people tend to come back to where they come from’. (FG2; female; PGY2)
		‘My partner works at a job in the city and what do we do with our daughter if we move rurally. Unless they can make it attractive for the whole family, it’s going to be seen as a stress’. (P02; female; PGY1)
		‘it’s important to have grandparents who can provide support and stability for my child education’. (P06; male; MD2)
	Stigma towards rural psychiatry	‘People in rural area may not be exposed to many acute psychiatric illnesses, so there’s still a lot of negative stigmas’. (P10; male; PGY2)
		‘It worries me to do psychiatry in a rural town, because everyone would know where you live and there’s less anonymity’. (P09; female; PGY1)
		‘A big barrier you would see the patients around and especially in rural psychiatry that is more of an issue than other areas of medicine’. (FG1; male; MD3)

Enablers

Clinical exposure to rural psychiatry

PIF members reported their positive rural psychiatry experience as the main driver for pursuing rural psychiatry. Increased autonomy and more time spent with psychiatrists and psychiatry registrars in rural settings highlighted psychiatry’s unique traits, characteristics and evolving landscape. Exposure to rural psychiatry also provided positive role modelling and mentorship opportunities for medical students and junior doctors.

Personal factors

Most participants reported that they intended to pursue psychiatry as a career before commencing medical school. This was often driven by participants’ personal and family experiences with mental health. Previous professions before medicine also provided inspiration to pursue psychiatry. Furthermore, participants’ rural background was a strong determinant for pursuing a career in rural psychiatry or rural general practice with a particular interest in mental health as an alternative.

Rural psychiatrists’ lifestyle

Most participants observed that rural psychiatry offers an excellent work–life balance for doctors choosing to raise a family. Financial incentives, including rent subsidy, more affordable housing, cheaper cost of living in rural areas and the rural lifestyle, were identified as drivers. This was further enhanced by the broad scope of practice and the longevity of practising psychiatry as a career in rural areas.

Workforce shortage awareness

Participants identified altruistic value as a motivator for pursuing a career in rural psychiatry. Participants reported their inclination to provide psychiatry services, especially in areas of need where access to a psychiatrist is scarce. Participants identified the newly introduced Rural Psychiatry Training Pathway as providing better opportunities to complete their psychiatry training in rural areas.

Barriers

Lack of rural infrastructure

Study participants perceived limited rural psychiatry training centres as the main barrier to pursuing rural psychiatry. They felt this issue was further compounded by the lack of consistency in psychiatry training application requirements and processes between the states and territories in Australia. Our participants found it challenging to find information about rural psychiatry training centre availability, even though this was an essential factor in choosing their internship and residency locations.

Study participants who had been exposed to rural psychiatry felt that the shortages in the rural workforce led to an increased workload and a lack of clinical support in rural psychiatry training networks, especially those staffed with fly-in-fly-out psychiatrists.

Appeal for urban psychiatry

Participants perceived more training positions and employment opportunities in urban centres. There was a perception that urban centres provided opportunities for more lucrative private practice options. Furthermore, the convenience of metropolitan living, such as access to international airports and more lifestyle choices, had a solid appeal to young people, making up most medical students and junior doctors.

Social isolation and family commitments

Study participants highlighted the importance of family and a broader support network when deciding where to pursue their careers. Partner’s limited employment opportunities and the lack of children’s education options in rural areas were often identified as barriers.

Stigma towards rural psychiatry

Participants reported their observations regarding the more pronounced stigma towards psychiatry from society and the medical community in rural areas. As a result, there was a perceived concern for safety issues in pursuing rural psychiatry due to the smaller population and lack of anonymity. This, combined with the complexity of managing mental health patients with dynamic risk profiles, was seen as another deterrent to pursuing rural psychiatry.

Discussion

Australia has a specialist training network that is focused on metropolitan centres.^5,6 Our study participants perceived that the availability of psychiatry training locations in rural and regional areas was still limited. As a result, psychiatry-inclined participants from rural backgrounds, wanting to stay rurally, were exploring alternative career pathways that offered the option of completing postgraduate training in rural and regional areas, such as GP with sub-specialisation in mental health.

Government programs, such as establishing Rural Clinical Schools and the Regional Training Hubs to promote medical student and postgraduate training in regional areas, attempted to improve the future rural workforce shortages. The RANZCP recently proposed the expansion of rural psychiatry training networks by increasing the availability and support for rural training centres that aimed to improve recruitment and workforce retention.⁵

Study participants felt that incentivising rural psychiatry training pathways to be more appealing than their urban counterparts would increase the appeal for rural training. Better remuneration, fewer on-call requirements, subsidised living expenses, better quality training experiences and support structure were identified as enablers. Monitoring, evaluating and supporting better rural training outcomes, including better results in specialist examinations, would further increase the uptake of rural training. Furthermore, promoting opportunities for career enhancement in rural psychiatry, such as leadership, advocacy, academic roles and opportunities to establish a private practice in rural settings, would mitigate some barriers identified in this study.⁵ Our participants felt their interest was not fostered enough throughout medical school due to limited rural psychiatry rotations and a lack of integration of psychiatry teaching. Previous studies suggested that improvements in psychiatry teaching could improve medical students' attitudes and promote psychiatry recruitment.^3,9

Some of our findings on pursuing rural psychiatry were consistent with the literature regarding the general pursuit of rural medicine. Participants from rural backgrounds affirmed the appeal of a rural lifestyle as a strong determinant for staying rurally. On the other hand, participants from urban centres reported that barriers such as social isolation, family support, partner employment opportunities and children’s education were limiting factors. This study confirmed that participants tend to stay close to family and support networks. These elements are not exclusive to pursuing rural psychiatry and are well-acknowledged in the literature.^3,10,11

The study has limitations; it is a purposive sampling of the psychiatry-inclined cohort and does not explore perceptions of the broader medical student and junior doctor group. Secondly, this study did not explore psychiatry trainees' and psychiatrists' perspectives who are already in the psychiatry training network and may have been exposed to rural psychiatry rotation and practice. However, the study identified strategies to influence potential trainees towards rural training and practice, effectively overcoming the maldistribution of the psychiatry workforce across Australia.

Conclusion

The Australian rural psychiatry workforce shortage is a complex and multi-faceted issue. It requires a collaboration among the RANZCP, universities, regional training hubs and the state and territory governments to increase the appeal of rural psychiatry as a profession. Improving rural psychiatry training conditions and incentivising the rural psychiatry workforce should be the focus. Reinforcing enablers identified in this study and mitigating barriers would assist in shaping the future of the Australian rural psychiatry workforce.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

William Darmawan

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