How does Australia train its psychiatrists?

Currently there are about 2000 practising consultant psychiatrists in Australia, 80% of whom are in private practice. In terms of training there are close to 700 trainees (registrars) with approximately 100 qualifying each year (Henderson, 2000). Training takes place all over the country but, as with many other aspects of Australian life, is largely confined to a small number of larger cities dotted around the coast of the mainland.

The Federal and State infrastructure that Australia bases much of its organisation on is also reflected in its Mental Health Act legislation. There is no nationwide Mental Health Act. Rather, each state has its own Act (albeit largely similar) and board of medical registration for practitioners — an equivalent of our General Medical Council.

Usually a doctor who wants to specialise in psychiatry must first complete 2 years as a medical officer after obtaining the MB BS degree. This can be in any broadly medical/surgical post provided it has been approved by the state board. The would-be trainee applies to the Royal Australian and New Zealand College of Psychiatrists (RANZCP) directly and will undergo a selection process involving an interview before being accepted and recognised by the College as a trainee. Once accepted it is down to the individual to search for a suitable 5-year training scheme to join. Entry onto such schemes is again by interview, however, in practice the two interviews (College and scheme) will often be merged to form one general entry interview.

The first year

The first year on a scheme is regarded as probationary. Trainees (or ‘registrars’, as they are called) will spend 12 months in two 6-month placements; usually in general adult psychiatry in a broadly similar fashion to newly appointed senior house officers (SHOs) on a British scheme. Towards the end of the first year, various assessments are made. First, a formal report of the trainee's progress together with a detailed patient case history of 3000-5000 words needs to be submitted. In addition, a clinical exam much like that experienced in MRCPsych Part 1 is taken. A trainee needs to pass all three to progress to the next year of training.

Academic course

In addition to being part of a training scheme, university and other courses related to the theory and practice of psychiatry are run much like our own Part 1 and 2 MRCPsych courses. These courses vary from state to state and culminate in a qualification such as a Master of Psychological Medicine (MPM), for example in Victoria. Unlike the British system, the course is optional, but despite this most trainees do enrol for the 5-year duration. The course is structured in a way to mirror the 5-year registrar training scheme dealing with phenomenology and a variety of clinical topics at the outset progressing onto neurosciences and methodology in later years.

Second and third years

The next 2 years or so are designed to enable the trainee to meet the criteria specified in the ‘Certificate of Eligibility for Section 1 Exam’ (RANZCP, 2000). This consists of further 6-month posts in psychiatric specialities such as old age, child & adolescent, consultation/liaison, etc. At the end of each post, a detailed case report must be submitted — six in total including the year one case. These will need to be approved before being deemed acceptable by the College.

In addition to case reports, requirements for psychotherapy training need to be met. Including at least two cases of short-term and one of long-term (>6 months) cognitive—behavioural therapy and dynamic psychotherapy. Also at least five sessions of marital/family/group work need to be undertaken. The individual trainee must organise and log these.

Also during the third year, a general medical examination (GME) is attempted. Its purpose is to underline the importance of a good working knowledge relating to physical medicine in everyday psychiatry. It consists of a clinical long case followed by a viva in the presence of two physicians. At present its future in this part of the exam is under review as it is felt to replicate much of what was examined at MB finals, but at the time of writing it is still a requirement.

The fourth year

This year is said by many trainees to be the most taxing of the 5-years. During this time the trainee must ensure that all the requirements for the ‘Certificate of Eligibility’ are present and up-to-date. Then, towards the end of this fourth year he/she can take the Section 1 exam. This exam is structured in a broadly similar way to aspects of the British MRCPsych Part 2 exam, consisting of both written and clinical elements. There are two written papers. The first is a series of short answer questions on neurosciences and theory followed by an essay paper covering broader clinical topics.

The oral exam is taken approximately 4-6 weeks following the writtens. This section of the exam is divided into 2 ‘days’. Day 1 consists of two long cases (each with two examiners). The presentation and resulting discussion are similar to that encountered in Part 2 MRCPsych. Day 2 is reserved for the so-called ‘consultancy viva’. Here, a variety of clinical scenarios and vignettes are presented and the candidate is asked to comment on, or manage them. Clearly, parallels with Part 2s ‘patient management problems’ are obvious. Provided both clinical days are passed then no further exams need be taken along the path to consultancy — the trainee can now progress to the fifth and final year of training.

The fifth year

This year is referred to as the elective year. Having passed all the exams, case histories and other training requirements, the trainee — now referred to as a ‘senior registrar’ embarks on the final phase of training before being granted Fellowship of the College. The purpose of this year is to enable the trainee to make career and speciality choices — the types of posts available to senior registrars reflect this.

The major requirement of this year is a 10 000-25 000 word dissertation, which will be submitted to the College for approval. It can be a literature review, a piece of original research, a clinical topic or a service development/evaluation paper. Normally, candidates complete this towards the end of their fifth year. If approved, the College bestows the much-coveted fellowship (FRANZCP) upon the trainee. In some cases a final viva, perhaps relating to the dissertation, is required. Once fellowship is granted, the senior registrar is regarded as a consultant psychiatrist and is eligible to practise independently, either privately or in the public system.

Advanced training

In recent years there has been a growing recognition that newly qualified consultants in certain psychiatric specialities require further specialised training. This is true of two areas at present — old age and child & adolescent psychiatry. To address this, the College has introduced a 2-year advanced training programme covering the elective year and the first year as a Fellow. The idea is to furnish the individual more adequately, with further skills and knowledge related to his or her chosen field.

British-trained psychiatrists

At present having the FRANZCP is recognised by our Royal College as a specialist qualification and is considered to be the equivalent of a Certificate of Completion of Specialist Training (CCST) in general adult psychiatry. There is not total reciprocal recognition between the FRANZCP and the MRCPsych, largely owing to the fact that the FRANZCP is an exit qualification rather than the MRCPsych being attained midway through training in the UK. Generally speaking, a holder of the MRCPsych who decides to obtain Australian College Fellowship will be exempted of various elements of the training requirements depending on experience and seniority. The general rule being that, ‘the more you do in the UK, the less you need to do in Australia’. While a newly appointed specialist registrar with the MRCPsych may still have days 1 and 2 of the clinical, the viva and dissertation to complete, an eminent consultant psychiatrist who holds the FRCPsych may only have a final viva to deal with — the subject matter largely being dictated by the applicant's seniority.

For those UK trainees eager to experience psychiatry in Australia on a temporary basis, there are many options. Several SHO/specialist registrar (SpR) schemes across the country operate exchange arrangements with equivalent Australian schemes. It is worth noting that up to 1-year of overseas training in SpR posts can be recognised by the UK College as counting towards a CCST. My own experience has proved that getting accreditation for this is not too big a hurdle to overcome provided the College receives details of the proposed plan in plenty of time.

On a personal note, I would say that I have been very fortunate in my experience of old age psychiatry in Melbourne. I believe it has helped me enormously and would encourage anyone considering a change of environment to seriously consider this as an option. Australia has much to offer on a personal and professional level — as for me, a winter without de-icing my car is reward enough!

Further information can be obtained by contacting: The Royal Australian and New Zealand College of Psychiatrists, 309 La Trobe Street, Melbourne, Victoria 3000 Australia (website: www.ranzcp.org ; e-mail: [email protected] ).