Recruitment and retention of psychiatrists in low-income countries

I have read the article Brown et al (Psychiatric Bulletin, November 2007, 31, 411–413) with great enthusiasm as its contents appear to be very relevant to low-income countries as well.

Recruitment into psychiatry seems to be a global issue. In addition to problems in recruitment, many psychiatrists and psychiatric trainees leave low-income countries in order to find more lucrative jobs in high-income countries. For instance, the Postgraduate Institute of Medicine, University of Colombo, Sri Lanka, has trained a reasonable number of psychiatrists over the past few decades. However, there are about 35 psychiatrists working in the country at present (about 2 psychiatrists per 1 million people). Obviously, this figure is grossly inadequate. Shortage of other professionals in the multidisciplinary team adds to the problem further. As a result of concentration of most of the psychiatrists in the cities, peripheries are poorly served.

In the Doctor of Medicine (MD; psychiatry) training programme in Sri Lanka there is a component of overseas training after completion of MD (Psychiatry) part 2 examinations. A survey among the trainees revealed that the majority preferred the UK centres for their overseas training and all indicated that they would like to return to Sri Lanka after their overseas training (details are available from the author upon request). However, it seems that once exposed to the overseas training and the Western lifestyle, many are reluctant to return. These issues were discussed at length at the recently held South Asian Federation of Psychiatric Association's Annual Academic Sessions in Kalutara, Sri Lanka.

We believe that there are a few options to reduce this crisis, for instance enhancing the recruitment of more doctors into psychiatry or improving the knowledge of psychiatry among primary care doctors. Already some medical schools in Sri Lanka (e.g. University of Kelaniya and University of Colombo) have addressed this issue and increased the psychiatry training component in their undergraduate curricula. One of them is Colombo Medical School where psychiatry is assessed as a separate subject in the final Bachelor of Medicine and Bachelor of Surgery (MBBS) examination. Soon psychiatry will be incorporated as a separate subject at the final year assessment at the Faculty of Medicine, University of Kelaniya.

The importance of improving the quality of undergraduate teaching in order to enhance the recruitment of medical graduates to the field of psychiatry has been emphasised (Sierles et al, 2003). When medical students are more knowledgeable, fear and stigma associated with psychiatry, which seems to be more prevalent in low-income countries such as Sri Lanka, become less prominent.

A recent survey carried out among undergraduates in medical schools in the Western Province of Sri Lanka demonstrated that the career choice in psychiatry is about 2%, which is less than in the Western world (details are available from the author). A study in Spain has shown that the career choice for psychiatry was 6%, compared with 4.5% in the USA (Pailhez et al, 2005).

Psychiatry seems to be a less attractive medical field globally. Overworked psychiatrists with minimum rewards for their work tend to lose their interest in the profession, which can adversely influence the quality of care and teaching. Psychiatrists should be aware of factors that will help them prevent that.

As medical teachers and practising psychiatrists we should also be aware of the problems encountered in psychiatry to enhance the recruitment and retention of psychiatrists.