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Mental Health Reforms in Europe: Challenges of Postgraduate Psychiatric Training in Europe: A Trainee Perspective
Alexander Nawka, M.D.; Martina Rojnic Kuzman, M.D., Ph.D.; Domenico Giacco, M.D.; Amit Malik, M.R.C.Psych., D.G.M.
Psychiatric Services 2010; doi: 10.1176/appi.ps.61.9.862
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The authors are members of the Board of Directors of the European Federation of Psychiatric Trainees. Dr. Nawka is affiliated with the Department of Psychiatry, 1st Faculty of Medicine, Charles University in Prague, Ke Karlovu 11, 128 00 Praha 2, Prague, Czech Republic (e-mail: nawka@seznam.cz). Dr. Kuzman is with the Department of Psychiatry, Zagreb University Hospital Centre, Zagreb School of Medicine, Zagreb, Croatia. Dr. Giacco is with the Department of Psychiatry, University of Naples SUN, Naples, Italy. Dr. Malik is with the Hampshire Partnership National Health Service Foundation Trust, Hampshire, United Kingdom. Matt Muijen, M.D., Ph.D., is editor of this column.

The European Federation of Psychiatric Trainees (EFPT) is an umbrella organization for trainee associations in 31 countries. A survey asked member countries about the three most important issues facing postgraduate training. Qualitative analysis grouped responses in five categories: implementation of new postgraduate curricula, poor working conditions, low recruitment of psychiatric trainees, insufficient training opportunities, and inadequate psychotherapy training. Disparities between countries lead to trainee migration, which worsens conditions in their home countries. The EFPT is in a unique position to obtain feedback and work with partner organizations to improve the standards of psychiatric training for European trainees. (Psychiatric Services 61:862—864)

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The European Federation of Psychiatric Trainees (EFPT) is an independent, nonprofit, umbrella organization for national European psychiatric trainees' associations. It was created in 1993 by a group of enthusiastic trainees with the foresight to understand the need for and significance of a European association that represents trainees in psychiatry (www.efpt.eu). The organization has continued to grow and currently represents psychiatric trainees from more than 30 countries in Europe (World Health Organization's definition of Europe).

The primary objective of EFPT is to enhance and harmonize standards of psychiatric education and training across Europe by working in partnership with relevant international or national bodies. Every year the EFPT president organizes the annual European Forum, where 60—80 trainee representatives from national psychiatric trainee associations come together to explore and work on issues of significance to psychiatric training in Europe.

As a permanent member of the European Board of Psychiatry and the European Board of Child and Adolescent Psychiatry, the EFPT actively participates in both the development of educational guidelines and the evaluation of psychiatric training institutions in Europe. Recently, the European Board of Psychiatry in the Union Européenne des Médecins Spécialistes (European Union of Medical Specialists) (UEMS) conducted a comprehensive survey on training in psychiatry in all member countries. Survey data showed substantial differences between training centers across Europe; however, notable progress toward developing high standards in training in psychiatry has been made in recent years (1). In many countries, especially in Eastern Europe, issues such as developing and sustaining psychiatric training programs present a significant problem (2). Within that context, the EFPT provides a unique opportunity for direct feedback from psychiatric trainees across Europe. The feedback is a rich source of information, which empowers the EFPT to work with other European organizations that aim to improve the standards of psychiatric training.

On the basis of the reports submitted to the annual forum by the national trainee associations, the EFPT develops specific action plans to meet the needs of its members. In 2010 a qualitative analysis of data in the country reports revealed some interesting findings, especially in response to the question, "What are currently the three most important issues facing postgraduate psychiatric training in your country?" Twenty-eight of 31 countries responded (90%), including 20 full-member and eight observer-member countries. Responses were grouped under five themes, which are discussed in the following sections.

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Implementation of new postgraduate curricula

New postgraduate training programs that follow a competency-based framework are being developed in a number of countries (for example, the United Kingdom, Ireland, and the Netherlands). Their components generally include a competency-based curriculum and assessment programs, ranging from assessments conducted in the workplace to exit examinations. Although the introduction of competency-based training represents a major shift in medical education and a challenge to harmonizing psychiatric training in Europe (3), its benefits are recognized and thus it is firmly supported both by the UEMS and the EFPT.

However, a significant proportion of trainees in countries where new training programs have recently been introduced have identified many challenges with this transition. First, there are concerns that adequate resources have not been made available to deliver this relatively resource-intensive method of providing postgraduate training. Concerns have been expressed about such issues as the provision of adequate exposure to both the experiential and didactic components of the curriculum, employer support of trainees in attaining the range of competencies across rotations, and availability of adequate assessor and educational supervisor time for adequate feedback and support as a trainee progresses through the curriculum.

Second, especially during the transition from an old to a new training system, there are concerns about both the clarity of regulations for trainees in transition and the length of the transition period. The issue of length becomes even more significant in light of the recent feminization of the medical work force (4). There is anecdotal evidence that female trainees are more likely to take maternity leave during this period and thus spend more time in training in an older training system. This can result in an even longer overall transition period. Finally, there are concerns about the quality assurance of nationally developed curriculum frameworks because trainees are experiencing a gap between the conception of training systems at a national level and their delivery at a local level.

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Working conditions

Although significant progress has been made in some areas to improve working conditions for postgraduate psychiatric trainees in Europe, especially with the implementation of the European Working Time Directive, the issue of working conditions continues to distress trainees significantly in many parts of Europe. In times of greater pressure on public health expenditures, mental health is traditionally seen as a "Cinderella" specialty and is at risk of experiencing disproportionate cutbacks. Within this context, training budgets are not usually protected, and thus training is a disproportionate victim when there are pressures to sustain essential clinical services. This vulnerability affects morale and often results in senior educators' retiring or moving to the private sector, with a consequent further negative impact on training.

In addition, unrelated to the current economic climate, there have historically been huge disparities between various parts of Europe in working hours, training budgets and resources, and pay for trainees, even when mitigating factors such as cost of living are taken into account. All these factors and the lack of adequate training facilities, high levels of service commitments, and poor career and pastoral support have two significant effects. First, as evidenced by the preliminary results from the International Psychiatry Resident/Trainee Burnout Syndrome Study, which was carried out in several European countries, trainees suffer from at least a moderate level of burnout (5). Second, because borders within Europe are disappearing, trainees migrate to areas of better working conditions in Europe, thus leading to a further deterioration of the mental health workforce in resource-poor countries. This deterioration exacerbates the vicious cycle of poor training conditions and further migration.

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Low recruitment of trainees

According to the World Health Organization a chronic worldwide shortage of psychiatrists has impaired the delivery of first-class mental health care (6). The shortage affects most European countries—for example, Austria, Sweden, Norway, the United Kingdom, and Israel. Recruitment into psychiatry from medical schools is one of the biggest challenges the profession is facing. The situation is even more pronounced outside major urban centers. This problem tends to become a vicious circle, because shortages contribute to stressful working conditions and to problems with implementation of prescribed training programs. The shortage of specialists imposes large patient caseloads on trainees, who are left without much-needed supervision because senior physicians are overloaded. Such a situation can contribute to low life satisfaction and feelings of inadequacy among trainees, which in turn makes psychiatry even less attractive to medical students.

There is an urgent need for a better understanding of the rejection of psychiatry by most medical students. This is a priority for the global psychiatric community. To this end, the World Psychiatric Association recently awarded a grant to the Royal College of Psychiatrists to examine challenges facing recruitment. The College is coordinating the International Study on Student Career Choice in Psychiatry (ISoSCCiP) along with its EFPT partners to understand and address recruitment challenges across the world.

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Insufficient training opportunities

In some countries, even where there are shortages of specialists in psychiatry, trainees are significantly disenfranchised by the lack of timely training opportunities at the specialty and subspecialty levels, although this may appear counterintuitive when considered along with the issue of poor recruitment. For example, in some Eastern European countries, formal residency training programs in psychiatry are shorter than a year and trainees acquire most of their knowledge through courses outside the training program. In most countries, however, the problem is related more to inadequate implementation of the training program than to the structure or length of the program itself. For example, in some countries, such as Greece, trainees must wait for up to four years before they can obtain a specialist training post. In others, this shortfall exists at the subspecialty level, in areas such as psychotherapy or forensic psychiatry. In addition, trainees experience difficulties accessing mandatory placements in nonpsychiatric specialties (such as internal medicine, neurology, and surgery), either because of a shortage of these opportunities or the inflexibility of psychiatric employers.

On the other hand, some trainees expressed concerns regarding the provision of clinical and educational supervision. A few described working in emergency rooms without adequate clinical supervision, which raises serious concerns about patient safety and the quality of clinical care.

The situation is further complicated in part by the lack of accredited or high-quality facilities in many parts of Europe (especially in the eastern and southern parts) and the heterogeneity of standards of training and teaching at training centers in the same country. Heterogeneity is also evident in didactic training and in the range of clinical and educational exposure provided by training centers. Some centers do not provide sufficient experiential training opportunities, resulting in oversubscription of centers that do. This variability leads to migration of trainees to these "good" centers at great personal and financial cost to them, creating further disparity between "good" and "bad" training centers. Also, in some countries there are statutory requirements for trainees to undertake the majority of their psychiatric placements in university hospitals. Either way, some trainees temporarily relocate and leave their homes and families for several months each year. This demanding change has a significant impact on their quality of life and training experience. The system is crying out for adequate accreditation and quality assurance mechanisms—at least at a national level but, ideally, conforming to European standards for psychiatric training (1). Overall, the inadequate training often leads trainees to migrate to other countries where better opportunities exist—mostly to Western and Northern European countries, such as the United Kingdom, Ireland, Sweden, and Norway.

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Psychotherapy training

There are three specific issues regarding psychotherapy that concern trainees throughout Europe. First are concerns that not enough clinical opportunities are available to meet the training and curriculum needs of most trainees. Second, there are concerns about the funding and availability of psychotherapy courses. Many courses are very expensive, and trainees are expected to pay for them. Finally, although the importance of personal psychotherapy for psychiatrists is widely acknowledged, it is not required in most countries and very few countries provide financial resources in their training programs to support personal psychotherapy for psychiatric trainees.

This column presents a trainee perspective on the major challenges in psychiatric training in Europe. Although some concerns reflect issues in the wider health community and are not directly related to training programs, all of the challenges described here were cited by European trainees as the most significant ones for European psychiatric training.

As noted above, educational systems in some European countries have undergone major reforms and are now implementing a competency-based approach to training. A major concern reported by trainees pertains to the implementation of these new programs rather than to the structure or content of the curricula themselves. It is of utmost importance to develop clear quality assurance strategies not only to ensure adequate implementation of new training programs but also to evaluate and address some of the other concerns of trainees described here.

The reports of the training program consumers make it clear that substantial differences in quality of training exist across European countries. The survey provides anecdotal evidence that an east-to-west and north-to-south gradient of training opportunities and working condition exists in Europe. This gradient appears to be correlated with patterns of brain drain and professional migration. It is imperative that statutory and professional bodies invest their energy and resources to further investigate the existence of such a gradient and, if it does exist, to identify and try to minimize its causes in order to raise the standards and quality of postgraduate training across Europe.

Many voluntary initiatives have been undertaken by national trainee associations to attempt to ameliorate some of the nation-specific issues. For instance, the issue of educational and clinical supervision has been addressed by raising awareness of its importance and launching initiatives such as mentorship programs. Increasingly, national training organizations are also involved in the development and delivery of new curricula, and it is hoped that with time this involvement will help raise trainees' awareness of the challenges of these systemic changes. Most important, in a majority of European countries, trainees have acquired representation in educational bodies to ensure that the trainee voice is heard and a trainee focus is retained in modernizing and improving postgraduate training in Europe.

On an international level, all national trainee associations are represented in the EFPT and engage with statutory and professional European bodies through the EFPT. Therefore, the EFPT is in a unique position to obtain representative feedback from psychiatric trainees across Europe and then work with our partner organizations, including the UEMS, European Psychiatric Association, World Psychiatric Association, and World Health Organization-Europe, to raise awareness of these issues and collaborate in finding solutions to help improve the standards of psychiatric training for European trainees. This will eventually benefit our patients by enhancing the overall quality of mental health care in Europe.

Lotz-Rambaldi W, Schäfer I, ten Doesschate R, et al: Specialist training in psychiatry in Europe: results of the UEMS-survey. European Psychiatry 23:157—168, 2008
 
Muijen M: Mental health services in Europe: an overview. Psychiatric Services 59:479—482, 2008
 
Oakley C, Malik A, Kamphuis F: Introducing competency-based training in Europe: an Anglo-Dutch perspective. International Psychiatry 5:100—102, 2008
 
Wilson S, Eagles JM: The feminisation of psychiatry: changing gender balance in the psychiatric workforce. Psychiatric Bulletin 30:321—323, 2006
 
Jovanovic N, Beezhold J, Andlauer O, et al: Burnout among psychiatry residents: the International Psychiatry Resident/Trainee Burnout Syndrome Study (BoSS). Die Psychiatrie 6:75—79, 2009
 
mhGAP: Mental Health Gap Action Programme: Scaling Up Care for Mental, Neurological, and Substance Use Disorders. Geneva, World Health Organization, 2008. Available at www.who.int/mental_health/mhgap_final_english.pdf
 
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References

Lotz-Rambaldi W, Schäfer I, ten Doesschate R, et al: Specialist training in psychiatry in Europe: results of the UEMS-survey. European Psychiatry 23:157—168, 2008
 
Muijen M: Mental health services in Europe: an overview. Psychiatric Services 59:479—482, 2008
 
Oakley C, Malik A, Kamphuis F: Introducing competency-based training in Europe: an Anglo-Dutch perspective. International Psychiatry 5:100—102, 2008
 
Wilson S, Eagles JM: The feminisation of psychiatry: changing gender balance in the psychiatric workforce. Psychiatric Bulletin 30:321—323, 2006
 
Jovanovic N, Beezhold J, Andlauer O, et al: Burnout among psychiatry residents: the International Psychiatry Resident/Trainee Burnout Syndrome Study (BoSS). Die Psychiatrie 6:75—79, 2009
 
mhGAP: Mental Health Gap Action Programme: Scaling Up Care for Mental, Neurological, and Substance Use Disorders. Geneva, World Health Organization, 2008. Available at www.who.int/mental_health/mhgap_final_english.pdf
 
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