ROMANIAN PSYCHIATRIC RESIDENTS’ OPINION ON FACTORS WHICH INFLUENCE THEIR DECISION TO EMIGRATE AS CHALLENGE FOR REFORMS IN EDUCATIONAL AND MEDICAL SYSTEM IN PSYCHIATRY

INTRODUCTION
T h e R o m a n i a n p h y s i c i a n s , a n d b e t w e e n t h e m psychiatrists, experienced an important rate of migration in European countries after 2007, when Romania became EU member. There were many concerns in media about the “brain drain”, emigration of highly skilled health professionals from less developed to developed countries (1). The number of psychiatrists in Romania varied from 4.2/100 000 habitants in 2001, to 6.45/100000 (2), respectively 5.97/100000 in 2014 (3), lower than other European countries (9 psychiatrists/100 000) (2, 3). There is important variance between the number of psychiatrists in university centres (8.5/100000 in Bucharest, 8.3/100000 in Iasi and 5.4/100000 in Targu Mures) and other regions (3.2/100000 in Covasna si Giurgiu).
The most popular countries for migration of Romanian psychiatrists are France, Germany and the United Kingdom (4) and in the last years also in other countries (Sweden, Norway) which have active policies in recruiting external personnel because of shortage in mental health workforce (5).
The migration of residents and/or young specialists was a major concern of Ministry of Health which elaborate a strategy of human resources in health care system (3).Despite of different measures taken for reducing the migration (a guarantee of a working place in regions with low number of psychiatrists and increasing the salary) this phenomenon continued. The official records show that comparing 2007 vs. 2014, the number of both psychiatric residents and young specialists (with less than 5 years of professional experience) which migrate in EU countries was doubled, and represent approximately 10% of total number of trained professionals in the same period. The numbers of specialists with more than 5 years of work experience which migrate remain constant and very low (1/year) (data from National Romanian College of Physicians).
The job satisfaction depends not only on salary and financial benefits but also on other factors as work–life balance, facilities for employee comfort, work facilitation, self-achievement and satisfaction, sense of accomplishment, self-esteem, workload, work stress, job security, responsibilities and decision making, relationship with peers, work satisfaction, recognition, role clarity, career growth, pride, etc. (6).
STUDY HYPOTHESES
Not only financial reasons motivate residents in psychiatry to leave Romania. Identification of main factor could be the starting point of a strategy of retaining residents in psychiatry in country.
OBJECTIVES
To identify the factors related with residents in psychiatry decision of remaining and work in Romania or emigration in other EU countries and to do a prioritization exercise of main factors. Secondary objective was to provide some guidelines for elaborating a strategy to reform the educational and medical system in psychiatry starting from residents’ opinion.
MATERIAL AND METHOD
Study setting
The study was conducted in Romania, an East European country with a total land area of about 235 000 square km and a population of about 20 million people. The selection criteria for entry into psychiatric training are represented in Romania by a national exam where all graduated medical students can participate. In order of the grade obtained they could chose the preferred speciality. The total number of psychiatric residents admitted in training since 2011 is 512. There is a national psychiatric training program and the training take place in 6 university settings.
Methods
Because of the limited state of research, we have chosen an explorative research strategy that combines qualitative and quantitative methods. The study is a cross sectional evaluation at national level, on a randomised selected sample of Romanian psychiatric residents that express their opinion the factors which influence decision of migration in EU countries.
We randomly selected the target population of residents in psychiatry. From the total number of residents admitted in training in psychiatry (512) we excluded those (98) which have to sustain the specialist exam in 2015. We estimated a number of 414 residents in all years of training. We calculate that the sample size has to be equal with 80 residents for being quantitative and qualitative representative with a precision of +5%. For national randomisation, we divided the Romanian territory in 4 geographical regions and for each region we identified the list of all residents in training. We contacted every fourth on the list and plan an individual meeting for study purpose. The study was a voluntary one, no incentives were used. If one resident did not agree to participate, we contacted the next in the list. The response rate was
86.75% (92 residents were contacted). If the resident agreed to participate we used a self-administered, semi- structured questionnaire, the data were collected in paper and pen format. For ranking different factors, we used a prioritisation exercise and ask each resident to quote from
1 to 9 each factor (1 less important, 9 the most important).
Statistical analysis
For obtaining the ranking score we have calculated the average score allocated to each item. This score reflects not only the position on each resident choice but also depend on frequency of being chosen by different residents. In calculation of percentage of residents which consider on the first place a specific item, we excluded the residents (16.25%) which did not express a clear choice for first place in ranking and/or quoted with maximum score – 9 – more than one item.
Ethical issues
The data were collected in confidential manner, no identification data collected. We protect both individual and institutional identity. The data will be presented only on national and regional level for the same issue. The study received the IRB approval at the local ethical committee IPPD Institute of Psychotherapy and Personal Development, Targu Mures, Romania.
RESULTS
There are no statistical differences between characteristics of residents from different regions. In table 1, we presented the sample demographical (age, gender, marital status) and professional characteristics (as work experience in years, workload -working hours/week, night shifts/month, type of working place). All residents who participated in the study live in urban area. Keeping in mind that the period of 5 years represents the total duration of psychiatric residency and in the last years the number of residents that have been admitted in psychiatric training increased gradually the average of 2.28 years of work experience and that represent a characteristic of all population of psychiatric residents. In our sample of psychiatric residents population are more represented by female residents (72.5%), average age 29.07 years old, single, which work in hospital setting, similar amount of working hours/week (35.71). The average salary of a resident in psychiatry increased from 3600$/year in 2010 to 7800$/year in 2015.The work duration including the night shift are stipulated at 35 hours/week. The majority of residents in psychiatry work in university hospitals (93.75%). We excluded from the table presentation the working place items like community psychiatry, day centres, and research or academic units because the responders did not choose these answers.
Moreover, 75% of resident’s answer that they consider the possibility of working abroad in next years, but majority of them (71.66%) intend to work abroad for a limited period of time and only 28.33% of them intend to emigrate. 5% of residents in psychiatry intend to change the speciality or plan to choose another profession.
The factors evaluated were associated in 3 groups. (Table
2) First group of considered advantages for working abroad highlight that even residents high quoted the better salary (ranking score 6.8), better working (6.5) and living conditions (6), more than one third (37.31%) of residents ranked on first place better working conditions and
17.91% of them agreed that respect and appreciation by colleagues is the first factor what motivate them to work abroad.
The important role of nuclear and extended family in Romanian tradition and culture is reflected also by agreement of residents (64.18%) to consider “Being far from family members” as an important disadvantage of working abroad. Language difficulties, especially in a speciality as psychiatry, have to be taken into consideration, but are on first rank only for 13.45% of subjects.
As proposed measures for improving actual situation of psychiatric residents in Romania, the responders ranked on the first place the need of improving postgraduate education in psychiatry in general (34.33%) and in psychotherapy in special (26.87%). The importance of personal psychotherapy is underlined by residents which quoted on 3rd places in list of measures need to be taken, with 5.07 as cumulative rank score.


DISCUSSIONS
The items as better working conditions and better living conditions which are highlighted by Romanian residents are common with their colleagues from other low-income countries (5-8). There are also items quoted as important which are specific for Romanian population as respect and appreciation by colleagues and the importance of family relationships.
The Government and especially the Ministry of Health were concerned about the mental health workforce’ deficits and about the residents’ condition and as a consequence of these facilitated some specific measures (3). There were some measures concerning the availability of workplace, the residents and specialists’ salary, the accommodation conditions for young adults, the number of residents admitted in training and changes in national training program.
For a better distribution of the mental health workforce, it was organised for several times, a national exam for the residents entry on psychiatric training associated with 5 years’ work contract after the end of psychiatric training on a specific working places (with high deficits in qualified personnel). Even the residents participated with enthusiasm to this exam; the measure had not expected result because not all residents respect the contract after the end of training period and the workforce deficit persist. The salaries of residents and specialists increased gradually in last decade, but still remain 2 – 6 times lower than average salary in EU countries. There were states that supported facilities for a bank loan for apartment acquisitions for young adults.
There are several changes which have been done in national psychiatric curriculum in order to improve the quality of postgraduate psychiatric training as: increasing recommended duration of training in psychotherapy, rotation on different psychiatric sectors and sub- specialities highly recommended, child and adolescent psychiatry training, changes in total duration of training, etc. The effect of these changes was very low in practice because of the difficulties related with implementation of these recommendations.
The future strategy of reforms in educational and medical system in psychiatry has to implement the proposed changes in practice and take measures which facilitate changes in medical system simultaneously. If the clinical and academic workload of trainers is high the time allocated to mentoring and supervision of residents is low. Any changes involved both academic and clinical setting. The majority of residents have their experience only in psychiatric hospitals because of the lack of access to specific psychiatric settings (forensic, addiction, liaison p s y c h i a t r y, c o m m u n i t y p s y c h i a t r y, d a y – c a r e , psychotherapeutic centres) which are present only in few locations or in private sectors. The involvement of different sectors of psychiatry in educational process could be useful. For improving the workplace condition of residents, the medical hospitals where residents work have to be adapted not only to medical tasks but also to educational process. The lack of space in hospitals, absence of a room for residents was underlined as important factor of stress and burnout in psychiatric residents (9). Complex measures have to be taken.
The training in psychotherapy is a part of psychiatric curriculum but there are only few places where is put in practice because of the lack of trainers and of financial and practical conditions for being done. The assessment of the quality of a training program includes academic aspects,
working conditions and workplace assessment. The evaluation of academic aspects includes the qualification of trainers, an increasing number of trainees allocated to one supervisor, structure of theoretical courses, cases presentation, problem solving cases (10). It is important to understand the real conditions of training and accessibility to supervision in order to assess the workplace. Supervision have to include clinical supervision, individual supervision and supervision in psychotherapy. Assessment of working conditions also includes workload, numbers of duty hours, number of patients examined by each trainee per day, presence of a trainees’ room and a consultation room (10). An international independent team of assessment of training centres, as UEMS (European Union of Medicines Specialists) recommended, could be helpful in identification of specific measures need it in each setting.
STUDY LIMITATIONSThe sample was randomly selected at the national level and it is considered representative for a group of Romanian residents in psychiatry. Study limitation could be related with the fact that the results could be influenced by the personality traits of responders, which was not evaluated.
CONCLUSIONS
The factors which influence residents’ decision to emigrate represent the starting points on futures reforms in educational and medical system in psychiatry.
Implications for Academic Leaders
-workplace assessment has to be part of training program assessment
-the minimum training in psychotherapy is need it as part of postgraduate psychiatric training
-postgraduate training could be improved with constant evaluation of individualised resident educational needs ACKNOWLEDGEMENTS
We are grateful to the Mr Chiurciu Catalin from National Romanian College of Physicians, which contribute with the official data collection.
DISCLOSURE
The authors have no competing interests to disclose.

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