The plight of psychiatry IMGs as they hit our sunny shores.

It is pleasing to see the AMA take up the fight for probably the most disadvantaged and discriminated group of medical colleagues. International Medical Graduates (or IMGs) are doctors who are currently working here in Australia but have completed their basic specialty training in a country outside Oz. We know that IMGs make up at least 25% of our medical workforce and are over-represented in fields of psychiatry, general practice and obstetrics-gynaecology. IMGs and their families are unable to access our Medicare system for health and cannot access public education. A parliamentary report, entitled ‘Lost in the Labyrinth’ provided a concise and thorough understanding of the current predicament facing many IMGs, and reflects my thoughts 3 years on from the time of writing. The report, like myself, has no problem with regulatory and professional bodies having high standards for doctors wishing to practice in Australia. Both my thoughts and the recommendations tabled in 2012 reflect the ongoing issues of transparency, streamlining of accreditation requirements and substantiation of the costs associated with this. Another concern is the variable ways of appealing decisions made by these bodies. I speak after having extensive experience coaching and mentoring psychiatry IMG’s.

I have met many IMGs since I began coaching and training them for the RANZCP fellowship examinations. Over this time the way they are assessed has varied, but for about 10 years they have been assessed on requirements that are the same as local trainees, however their results are segregated from those of local trainees. When IMGs were segregated for their examinations, the premise was that they would receive extra time in the examinations due to linguistic challenges, and the standard expected on the day was much higher than of a local trainee, taking into account their experience and qualifications overseas. However, over this time, the pass rates for IMGs remain consistently lower that than of local trainees in the two types of clinical examinations set by the RANZCP, the OCI’s and the OSCEs.

Psychiatry IMG’s and local trainees are now following a 2012 training pathway with the RANZCP. Those who have not progressed in time on the 2003 pathway, which ended in October 2015, have moved into the 2012 pathway. Some trainees may be repeating requirements and some are waiting to hear what their requiremement wil be. I know this as I have spoken to many psychiatry IMGs and local trainees in this position.

A ‘bermuda triangle’ for many psychiatry IMG’s

 

Psychiatry IMGs and their plight on our sunny shores
Traveling to Bermuda Perfect Beach

After spending many hours with IMG trainees I conceptualise the problem to be one of “keepings off” between 3 main players; the Australian medical council/regulatory medical boards (AHPRA), the state hospital system that employs them, and the RANZCP (our college for accrediting psychiatrists). IMG’s must meet certain criteria to obtain residency status in Australia, state hospitals have their standards and fill vacancies with the IMG workforce, and the RANZCP administers it’s requirments and standards when it comes to deciding whether they can work as psychiatrists and obtain an Australian fellowship. All 3 organisations have their own set of criteria and benchmarks that IMG’s must fulfill, but they are raley streamlined, leading to confusion and misunderstanding.

Performance in RANZCP examinations

Many IMGs facing repeated attempts at the examinations. It is not unusual for me to coach an IMG who has failed 5 times. they find themselves in the category of ‘failure to progress’ through to the Fellowship as the RANZCP moves onto a new training pathway. many are waiting to hear what their pathway will look like as of 2016, and whether they will indeed be able to make it to fellowship.

Psychiatry IMGs have endured low pass rates despite being provided an exam with extra time to help with linguistic difficulties. Many have attempted the examinations more than three times. In October 2015, the last round of the ‘old style’ clinical examinations or ‘OCIs’ the pass rate for local trainees was 55%, and IMGs 20%. In July 2015, the pass rate for local trainees was 60%, and IMGs 29%. Similarly, the pass rates for the July 2015 OSCE clinical examinations, which will continue under the new fellowship pathway were 80% for local trainees and 48% for IMGs.

Many of these IMGs who are failing repeatedly are working as psychiatrists in regional, rural and remote areas of Australia, with limited access to training and supervision.

Fees

There appears to be wide disparity between the fee structure for local trainees and IMGs. An IMG will spend over $15,000 in fees to the RANZCP in order to practice in an area of need.  They must pay $5030 for an assessment, including an interview. Their placement fee is $9370. This is over and above the fees imposed by the Medical Board of Australia, and on top of other administration fees imposed by the college.

Morale

Of recent times as I continue to coach and mentor IMG’s I have noticed a drop in morale amongst them. I know that for cultural reasons they find it very hard to speak up if struggling, and I have seen them crumble when they tell me how difficult it has been for themselves and their family. Many have been practicing psychiatry for years before coming to Australia, and moved their family here as part of a requirement to achieve fellowship in India or Sri Lanka, only to find they cannot get through the training program. Many that I have come to know over the years are now at a stage where their children are older and they are facing decisions of splitting the family so a parent can return home with the children for education, or whether they all go home.

Workforce

AIHW data shows that in Australia there are roughly 13 psychiatrists available for every 100,000 of population. In rural and remote areas, where I have spent some time working as a locum psychiatrist, the figure drops to 2 or 3. Because of restrictions on where IMGs can work, most of these spaces are filled with IMG’s or locums. If IMG’s choose to leave Australia there will be a dearth of service and care of those with serious mental illness. Many regional centres exist solely on a locum workforce, with very few or no permanent psychiatrists. I have been a locum in FNQ and then diagonally across to Lower Great Southern WA. I know we are facing a huge problem already that is only going to get worse.

Summary and recommendations

I am not singling out RANZCP by writing this article but this is the experience I have after working with many psychiatry trainees, whether they be local trainees or IMG’s. “Lost in the Labyrinth’ made recommendations, and provided evidence of similar situations occurring within RACP and RANZCGP. I write to support all IMG’s in general, as the AMA has recently done as well. But I think it really is time for action, the recommendations have been made and the IMG’s won’t stay forever to help our workforce if we don’t get it correct. The recommendations  outlined in the 2012 report “Lost in the Labyrinth” are really worth a read as they speak to simple strategies that would go a long way to removing a bermuda triangle on our sunny shores.

http—www.aphref.aph.gov.au-house-committee-haa-overseasdoctors-report-combined full report

http://www.hwa.gov.au/our-work/health-workforce-planning/health-workforce-2025-doctors-nurses-and-midwives

https://mhsa.aihw.gov.au/resources/workforce/psychiatric-workforce/

 

 

 

Throwing the branding baby out with the bathwater

I wasn’t expecting such a heated debate on Twitter when I woke yesterday, regarding the upcoming state RANZCOG congress, and now known as “Mirenagate”.  But I shouldn’t have been surprised because that’s exactly what happens on Twitter. The reason I love being a doctor on Twitter, and why I know social media has the power to change.

Some amazing doctors that I admire so much on social media, including Dr Nikki  Stamp and Dr Eric Levi has put forward their points of view regarding what could have been an absolute branding nightmare for the RANZCOG on 2nd January 2016. The Australian newspaper revealed that a branch of the RANZCOG was proposing a debate on whether female registrars should be given contraception to avoid breaks in training. It happened outside business hours, as these things often do,  and that is exactly why all organisations regardless of industry and craft need a strict social media policy that can firstly identify and secondly handle anything.

I call this a branding nightmare because I know as a coach and mentor of doctors in training, and past president of the AMA(Vic) Doctors in Training subdivision that the RANZCOG are leaders when it comes to providing flexible and supportive training for men and women. I speak as a total outsider, but hey they leave some other colleges for dead. I know that those within the RANZCOG have worked very hard to establish a brand, their college seal that when viewed by potential applicants, actually means something. To me it has meant that they mean business when it comes to workplace training and flexibility.

BRAND related text inside hand drawn jigsaw piece on chalkboard

This is why branding and mission statements are so crucial, and also why they are so vulnerable. Anybody of official status or anybody who represents the RANZCOG in a public forum needs to protect their brand and mission statement. This is especially at times of crisis, when negative comments hit the media, and should also reflect not just the content but the approach to training registrars. This includes choosing how to phrase topics on conference agendas.

I have spent the last three years learning the art and craft of branding and know a little bit about social media thanks to some wonderful friends I found in the Twittersphere. Oh and a brand accelerator program that cost a bomb. I am writing my article based on two viewpoints, but both on what branding means to me. Branding is powerful, so when messages are delivered that are inconsistent with a brand we feel we can trust, we feel let down. Speaking for myself, I felt hurt and disappointed to see such a progressive college take such a stance when choosing agenda topics, regardless of whether federal council knew about it, and also felt that eerie silence that follows when there is no official response, and the subsequent void which becomes swamped with outcry.

This article is an attempt to explain to those at RANZCOG why so many people were upset and shocked at the headline in the Australian magazine yesterday. I know the new owner of the @RANZCOG handle is an expert on branding and social media too, and I am not trying to tell him how to suck eggs. But maybe others within the college can listen to leaders like Dr Joseph Sgroi and take on what he knows about branding, consistency and social media.

I am also writing this as a mum who, like many who have spoken on social media, really copped a rough deal when pregnant. I wonder how many have suffered as they left parenthood until too late and now face infertility. Men and women that choose to share parenting roles (believe me I know that there a quite a few male registrars who are really looked upon as being totally selfish when choosing to go part time to share parenting).  So I couldn’t help but be shocked by the title for the debate at the RANZCOG congress. Even if it isn’t my college, once again I felt they were a college that were better than this, and it brought back what I put up with.

Here is my story, as a psychiatrist who only ever wanted to be a psychiatrist. At some stage I really wanted to specialise in child and adolescent psychiatry. I also wanted to have a baby. And soon because I went to medical school in my mid 20s, and time was ticking.

In 2006, I was working in an advanced training position in child and adolescent psychiatry, and passed my clinical exams when 15 weeks pregnant. I even blitzed the OSCE station based on a CPR scenario, with the mannequin placed at the feet of the examiners so I felt they could look down our tops as we did chest compressions. (The RANZCP did acknowledge this was a problem after quite a few complaints but female registrars were implicated and found to be at fault for not choosing correct work attire suitable for all work situations). Anyway I digress.

At 30 weeks gestation I developed gestational diabetes and hypertension.  At 34 weeks my beautiful son was born. The week before it was decided that I should step aside from my office bearer role within the AMA as it was a very important role and should be handed over to somebody that was not about to go on to maternity leave, rather than seeing out my term (at this stage I didn’t know what was to happen the following week, and trying to come to terms with BSL’s of 11 despite eating food resembling cardboard). The day I was to start insulin, I started being a mum.

I was meant to become a mum around early December 2006. My 12 month post with my teaching hospital would end in January, as all of us registers are only employed for 12 months, hence no accrual of any entitlements. There was no planning or offers of roles, or even a discussion about what my plans were with regards finishing my advanced training. Because I became a mum in October, I got a few extra weeks leave of maternity leave.  Maternity leave ended at the end of my 12 month contract, and in early February 2007, I was an unemployed mother of a premature baby with severe reflux. My post was given to somebody else, but not as a maternity leave role.

I know I was classified as unemployed, despite paying money to the RANZCP to apply for a ‘break in training’. Because outside of medicine, if you don’t have a job, you don’t have a job. None of this ‘just get back in touch and we’ll keep you in mind, we’ll see what we have when you are ready to return’. Westpac bank wouldn’t cop it. I was unable to refinance my mortgage as I was unemployed. That was only one of many examples.

So after coming up for air, and recognising the irony that I was working in a sub-specialty that is based on attachment, infancy and how easy it is to stuff it all up, I didn’t go back to child and adolescent training and I didn’t go back to that hospital. I focused on my beautiful son and made damn sure I didn’t mess up what I could manage when it came to attachment and bonding. I finished my training in general psychiatry and got out. Not only out of training but also the public mental health system.

I know that many of us get caught between the interface of our colleges and our workplaces, both blaming each other, and doing a lot of ’keepings off’.  That comes at a personal price to us. So yes when we see topics like what appeared in the Australian yesterday we will be hurt.  And when we believe in a brand that represents a college that we do look to as one of the better ones when it comes to caring for their trainees regardless of gender, we might take to Twitter and shout the sky down.