International Migration of Doctors,and Its Impact on Availability of Psychiatrists in Low and Middle Income Countries

Background

Migration of health professionals from low and middle income countries to rich countries is a large scale and long-standing phenomenon, which is detrimental to the health systems in the donor countries. We sought to explore the extent of psychiatric migration.

Methods

In our study, we use the respective professional databases in each country to establish the numbers of psychiatrists currently registered in the UK, US, New Zealand, and Australia who originate from other countries. We also estimate the impact of this migration on the psychiatrist population ratios in the donor countries.

Findings

We document large numbers of psychiatrists currently registered in the UK, US, New Zealand and Australia originating from India (4687 psychiatrists), Pakistan (1158), Bangladesh (149) , Nigeria (384) , Egypt (484), Sri Lanka (142), Philippines (1593). For some countries of origin, the numbers of psychiatrists currently registered within high-income countries'' professional databases are very small (e.g., 5 psychiatrists of Tanzanian origin registered in the 4 high-income countries we studied), but this number is very significant compared to the 15 psychiatrists currently registered in Tanzania). Without such emigration, many countries would have more than double the number of psychiatrists per 100, 000 population (e.g. Bangladesh, Myanmar, Afghanistan, Egypt, Syria, Lebanon); and some countries would have had five to eight times more psychiatrists per 100,000 (e.g. Philippines, Pakistan, Sri Lanka, Liberia, Nigeria and Zambia).

Conclusions

Large numbers of psychiatrists originating from key low and middle income countries are currently registered in the UK, US, New Zealand and Australia, with concomitant impact on the psychiatrist/population ratio n the originating countries. We suggest that creative international policy approaches are needed to ensure the individual migration rights of health professionals do not compromise societal population rights to health, and that there are public and fair agreements between countries within an internationally agreed framework.     

Integration of mental health into primary care in Sri Lanka

Introduction Sri Lanka has one of the highest suicide rates in the world, with recent protracted conflict and the tsunami aggravating mental health needs. This paper describes a project to establish a systematic “train the trainers” programme to integrate mental health into primary care in Sri Lanka''s public health system and private sector.Methods A 40 hour training programme was delivered to curriculum and teaching materials were adapted for Sri Lanka, and delivered to 45 psychiatrists, 110 medical officers of mental health and 95 registered medical practitioners, through five courses, each in a different region (Colombo, Kandy, Jaffna, Galle and Batticola). Participants were selected by the senior psychiatrist of each region, on the basis of ability to conduct subsequent roll out of the training. The course was very interactive, with discussions, role plays and small group work, as well as brief theory sessions.Results Qualitative participant feedback was encouraging about the value of the course in improving patient assessments and treatments, and in providing a valuable package for roll out to others. Systematic improvement was achieved between pre- and post-test scores of participants at all training sites. The participants had not had prior experience in such interactive teaching methods, but were able to learn these new techniques relatively quickly.Conclusions The programme has been conducted in collaboration with the Sri Lankan National Institute of Mental Health and the Ministry of Health, and this partnership has helped to ensure that the training is tailored to Sri Lanka and has the chance of long term sustainability.     

Psychiatric manpower in British Columbia.

The ideal psychiatrist population ratio of 1:11 000, as accepted by the Ministry of Health in British Columbia and the British Columbia Medical Association, is probably inadequate since it does not take into account increased utilization and demand, the ageing of the population, the reduction in the work week of psychiatrists and the expected absence of of increased productivity of psychiatrists. The increase in utilization and demand reflects treatment of disorders with high prevalence and chronic outcomes whose needs were previously met, rather than psychiatrists "chatting with the worried well", as is sometimes alleged. The concentration of psychiatrists in Vancouver reflects the needs of both tertiary care and migration of psychiatric patients. It is not a local aberration and does not reflect over supply. An adequate psychiatrist to population ratio for large geographic areas is less than 1:10 000. The ratio for urban areas has not yet been determined, but is probably less than half of the overall ratio. In any case, more study of this issue is required before draconian health policy measures are undertaken to solve a perceived problem which may not exist.     

THE RELATIONSHIP OF THE REFERRING PHYSICIAN TO THE PSYCHIATRIST

The relationship of the referring physician to the psychiatrist is believed to be of a different order than that of most physicians to one another. Certain facts are postulated as playing a role in this somewhat difficult relationship and examples from actual practice are offered as evidence. Among possible points of discord are mentioned: The length and cost of psychotherapy and relative youth of the specialty, the referring physician''s hostile feelings toward it, and the unhelpful attitude of certain psychiatrists.     

Developing primary health care.

Primary health care is best provided by a primary health care team of general practitioners, community nurses, and other staff working together from good premises and looking after the population registered with the practice. It encourages personal and continuing care of patients and good communication among the members of the team. Efforts should be made to foster this model of primary care where possible and also to evaluate its effectiveness. Community services that are not provided by primary care teams should be organised on a defined geographical basis, and the boundaries of these services should coincide as much as possible. Such arrangements would facilitate effective community care and health promotion and can be organised to work well with primary care teams. The patient''s right to freedom of choice of a doctor, however, should be retained, as it adds flexibility to the rigidity of fixed geographically based services.     

Prison became second home for psychiatrist (George Scott).

Retired prison psychiatrist George Scott recalls his career working in Canada''s penal system, including his peacemaking role in a hostage-taking incident and his work with Steven Truscott. Life "inside" is dangerous for guards, inmates, staff and psychiatrists, he says, but he never regretted his decision to devote his career to studying criminal behaviour.     

Attainment of Optimum Health

The history of the worker in public health is reviewed, his present activities are assessed, and predictions are made concerning his future role. It is emphasized that the public health specialist is but one member of the total health team in the community. His interdependence with other disciplines must be accepted if optimal health care is to be provided.Although prepared specifically for public health workers, this article has direct relevance to the future of the medical profession as a whole. In view of the present intense interest in the future pattern of health care in Canada, the viewpoint of a physician with a dual background in public health and medical school administration and teaching is considered to be particularly pertinent.     

A Psychiatric Home Care Program: A Report on Three Years' Experience (1962-1964)

The activities covering a three-year period of a psychiatric home care treatment program attached to a psychiatric unit of a general hospital are described. A detailed account of its operation and the roles played by each member of the team is given. This service frequently provides a substitute for hospitalization in the management of both acute and chronic psychiatric states and thereby constitutes an important preventive measure in the field of public health. Even if the initial attitude of the patient is negative it is possible to gain the co-operation of the family who become a useful ally in the treatment. The co-operation of the patient is not as essential as has been thought. The traditional role of the psychiatrist is reversed by virtue of his attending the patient at home. The active participation of social agencies is an integral part of the treatment.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

The Isis Centre: a counselling service within the National Health Service.

A new centre has been established to provide readily accessible counselling, consultation, and mental health information. People may refer themselves or are recommended to attend by general practitioners or other agencies. The counsellors have varied backgrounds in paramedical or counselling services, and they are supported by psychiatrists. Of a sample of 100 clients, four were referred to one of the team''s psychiatrists and 33 visited the centre only once. The centre''s staff aim to adopt a flexible approach to the client and his problems, and formal psychiatric categories have not been found useful. Provision is made for people who want to solve their problems by discussion rather than medication and those for whom the existing psychiatric services may have little time to spare. Consequently, the approach adopted by the Isis Centre, whereby many people benefit from psychotherapy yet the psychiatrist deals directly with only a few selected cases, contributes towards meeting the great need for psychiatric services and using the psychiatrist''s skills more effectively.     

Cervical Cancer—Use of a Non-Physician Health Team for Screening Procedures

A team of non-physician personnel has been trained in cytologic screening for cervical cancer. In a county hospital clinic setting among low income women whose annual pelvic examinations were being by-passed by physicians, this three-person team has performed pelvic examinations and screening under physician supervision for one year.Results of the first year''s experience, measured in cancer detection and in recognition and referral of benign gynecological disease as well, would suggest that a non-physician team, with a registered nurse doing a pelvic examination of screening type, can screen for cervical cancer and other pelvic disease efficiently and without a significant lowering of the quality of medical care.The training and use of teams of allied health care personnel directed by physicians is suggested as a practical means of overcoming the increasing shortage of physician services in annual screening for cervical cancer among low income women.     

REPORT FROM OTTAWA

In a national disaster, the medical profession would lose physicians and auxiliary personnel and would need assistance. Canada''s 22,000 physicians and 85,000 nurses are located for the most part in potential target areas. Survivors among Canada''s 6396 dentists could supply 30% reinforcement. The dentist''s training, his manual dexterity and experience acquired in the management of hemorrhage, shock, débridement, suturing, reduction and immobilization of fractures, and control of pain and infection would be valuable. Additional functions he could perform would be first-aid, including but not limited to artificial respiration, early management of chest wounds, preparation of casualties for movement, and assistance in general surgical procedures. Dentists with special training in anesthesia, oral surgery or public health could be of particular value in relieving anesthetists, surgeons, radiologists and public health officers of some of their duties. Joint training of physicians and dentists in mass casualty care could increase the efficiency of the team work in disaster and is being considered by many medical and dental faculties.     

Association between the Density of Physicians and Suicide Rates in Japan: Nationwide Ecological Study Using a Spatial Bayesian Model

Background

Regional disparity in suicide rates is a serious problem worldwide. One possible cause is unequal distribution of the health workforce, especially psychiatrists. Research about the association between regional physician numbers and suicide rates is therefore important but studies are rare. The objective of this study was to evaluate the association between physician numbers and suicide rates in Japan, by municipality.

Methods

The study included all the municipalities in Japan (n = 1,896). We estimated smoothed standardized mortality ratios of suicide rates for each municipality and evaluated the association between health workforce and suicide rates using a hierarchical Bayesian model accounting for spatially correlated random effects, a conditional autoregressive model. We assumed a Poisson distribution for the observed number of suicides and set the expected number of suicides as the offset variable. The explanatory variables were numbers of physicians, a binary variable for the presence of psychiatrists, and social covariates.

Results

After adjustment for socioeconomic factors, suicide rates in municipalities that had at least one psychiatrist were lower than those in the other municipalities. There was, however, a positive and statistically significant association between the number of physicians and suicide rates.

Conclusions

Suicide rates in municipalities that had at least one psychiatrist were lower than those in other municipalities, but the number of physicians was positively and significantly related with suicide rates. To improve the regional disparity in suicide rates, the government should encourage psychiatrists to participate in community-based suicide prevention programs and to settle in municipalities that currently have no psychiatrists. The government and other stakeholders should also construct better networks between psychiatrists and non-psychiatrists to support sharing of information for suicide prevention.     

Over the counter drugs. The interface between the community pharmacist and patients.

Pharmacists play an important part in primary health care, and their accessibility is a key factor. Their NHS payments relate predominantly to the dispensing of prescribed medicines; to recognise the service element of their advisory role, an NHS funded professional fee could be built into the cost structure for pharmacy medicines. The increased number of medicines available over the counter has highlighted the need for training for counter assistants; it will become compulsory in July 1996, and some family health services authorities are providing this. The shift to care in the community could mean that pharmacists will have an even greater role in the primary health care team. Encouraging the public to seek advice from the community pharmacist may lead to a greater proportion of visits to doctors resulting from referrals from the pharmacist. Joint development by pharmacists and doctors of guidelines for advice on, and recommendation of, over the counter medicines is needed.     

An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people.

OBJECTIVE--To determine the accuracy of psychiatric diagnoses made by two community psychogeriatric teams operating a multidisciplinary assessment procedure. DESIGN--Comparison of team diagnosis with independent formal assessment and consensus diagnosis by research psychiatrists. SETTING--Two community psychogeriatric teams with similar operational policies in an inner London health district. SUBJECTS--100 people aged 65-90 (70 women) newly referred to the teams. MAIN OUTCOME MEASURES--Concordance between team and research diagnoses. RESULTS--Agreement between team and research diagnoses ranged from 90% to 99% for the specific psychiatric disorders studied. There was no significant difference between medical and non-medical team members in their diagnostic performance compared with the research psychiatrists. Increased diagnostic accuracy by team members was associated with longer experience of team working, regardless of the team members'' professional background. CONCLUSIONS--The multidisciplinary approach to the assessment of referrals to these community teams for the elderly is not associated with misdiagnosis of psychiatric disorder.     

Working with the Family Doctor: A Programme for Mental Health

A new type of assessment for mental health in four Scottish counties has been based on multidisciplinary teams comprising psychiatrists, psychiatric social worker, nursing administrator, and a secretary. Each team collaborated with 15 to 20 family doctors and they established four main patterns of contact: around an outpatient clinic; by informal availability; by administrative and teaching seminars; or by regular consultation sessions. This improved contact was found to help both the team and the family doctors and reduced the number of patients admitted to hospital and the length of their stay and the number of urgent referrals. It emphasizes the need for team work in mental health care and that the hospital needs to remain in touch with the outside community.     

Health care cost effects of public use of a regional poison control center.

Poison control centers in the United States are threatened with closure, and attempts at a cost-benefit analysis of these services have been indeterminate. The purpose of this study was to compare the operating costs of a regional poison control center resulting from public use of its telephone hotline services with those of hypothetical alternative sources of advice and care. We conducted a follow-up telephone survey among 589 public callers to the San Francisco Bay Area Regional Poison Control Center who had been managed at home without medical referral after an unintentional poisoning. All survey respondents were asked what alternative action they would have taken had the poison control center not been available to assist them by telephone consultation. We then surveyed emergency departments and physicians'' offices cited as alternatives by the callers to determine their response and charges for evaluating a suspected poisoning case. A total of 464 (79%) of the callers surveyed would have sought assistance from their local emergency health care system had the poison control center not been available. We conservatively estimated that the total charges for such evaluations would be +71,900. Comparatively, the total actual operating cost of services provided by the poison control center for all 589 poisoning cases was +13,547. Most of the study subjects (429 [73%]) had private insurance coverage. Direct public access to these services probably reduces the use of emergency health care resources, thus lowering health care costs.     

Preventive Psychiatry: The Psychiatric Team as Consultant to the Public Health Nurse

Various forms of collaboration between the disciplines of public health and psychiatry are briefly reviewed and the 25-year-old mental health program of the Vancouver Health Department is described. The public health nurse has prime responsibility in all children with emotional disorders. She is supported by a psychiatric team which provides active treatment and educational and consultative help for the nurse and the school. During the year 1963, six social workers had 2357 contacts with nurses and school personnel but only 1049 treatment interviews. Of 401 children referred to the psychiatric team, 138 received active clinic treatment, 141 remained under supervision by the public health nurse, and 122 were referred elsewhere. In addition, 1330 children were identified as “mental hygiene cases” in the caseload of the 170 public health nurses in the community. By close co-ordination, the public health nurse and the psychiatric team can enhance each other''s contributions to community mental health.     

"Don't let others design your future", new CMA president tells physicians. Interview by Nancy Robb.

Dr. Judith Kazimirski of Nova Scotia becomes the CMA''s 126th president during the association''s annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they''re having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."     

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force’s findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.