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Abstract

Objective: New Zealand is suspected of sharing other countries' difficulties of having inadequate numbers of practising psychiatrists and attracting psychiatrists to work outside its main urban centres, but there is no contemporary data on the socio-demographic and professional practice profile of its psychiatrists. This paper highlights some interesting trends about New Zealand's psychiatric workforce.

Method: A postal questionnaire was sent to all actively practising vocationally registered psychiatrists with a New Zealand mailing address requesting information about basic demographic data, professional training experiences, current professional status, practise intentions, why they chose to work where they do and what factors might influence them to leave for another region of New Zealand or overseas.

Results: Of the 277 doctors on the vocational register for psychiatry, 159 responded, giving a response rate of 59.8%. Most psychiatrists were male (n = 102; 64.2%), European (n = 144; 90.6%), aged between 41 and 60 (69.2%), born overseas (n = 90; 56%), had English as their primary language (n = 142; 89.3%) and were in a long-term relationship with dependent children (n = 99; 62.3%). Nearly all (n = 149; 95%) did their psychiatry training in a metropolitan area and most (n = 108; 67.9%) held the Fellowship of the Royal Australian and New Zealand College of Psychiatry (FRANZCP). Most worked in a metropolitan area (n = 136; 85.5%) and either wholly or partly in the public sector (n = 145; 93%). Nearly one-quarter expected to retire over the next decade. Professional factors were rated more important as a reason for staying by metropolitan psychiatrists compared with their non-metropolitan counterparts (p < 0.001). Psychiatrists who did not have an FRANZCP (57% vs. 27%, p = 0.05), those who had spent more than 50% of their professional life in New Zealand (86% vs. 74%, p = 0.02) or those who had obtained their primary medical degree outside New Zealand were more likely to be in nonmetropolitan areas (81% vs. 49%, p = 0.04). Metropolitan psychiatrists rated personal and social reasons more highly than non-metropolitan psychiatrists did for factors which might induce them to leave for another area, whereas professional development was ranked lower.

Conclusions: This is the first contemporary study of New Zealand's psychiatric workforce and it highlights some interesting trends and has significant implications for those concerned with the recruitment and retention of psychiatrists. Further investigation is suggested, as a more complete picture of New Zealand's specialist psychiatric workforce would be gained by including psychiatrists who are not vocationally registered.

Keywords

career choice health manpower health services research physicians/supply and distribution professional practice location psychiatry

Two themes seem characteristic of the international contemporary psychiatric workforce: a suboptimal number of practising psychiatrists and a maldistribution between urban and non-metropolitan areas. Brockington and Mumford [1] have commented on the UK's need to recruit psychiatrists from overseas. Australia has one psychiatrist per 8598 population in urban areas compared to one per 35 723 in non-metropolitan areas [2], while only 7% of all psychiatrists in South Africa work in non-metropolitan areas [3]. There is also a possibility that the maldistribution of psychiatrists and their global suboptimal numbers could be interrelated.

New Zealand is not immune to these difficulties. The inadequate number of psychiatrists has attracted much media attention [4], [5] and it shares other countries' difficulties of finding psychiatrists to work outside its main urban centres [6], [7]. The previous Department of Health published some data on New Zealand's practising psychiatrists up to the 1980s. Since then, the health sector has been radically restructured, emphasizing the vaunted efficiency of market forces [8], which proposed that any national co-ordination of the psychiatric workforce was unnecessary. By the end of the millennium, the main agencies that systematically collected data on New Zealand's psychiatrists were:

• The Royal Australia and New Zealand College of Psychiatrists (RANZCP), which collected the name, gender, and age of its Fellows [9]. It does not collect information on psychiatrists who are not members of the College. This may not be an issue for Australia, where approximately 90% of all psychiatrists are RANZCP Fellows [9], but more than half of New Zealand's specialist psychiatric workforce is made up of doctors who are ‘overseas trained’ [10];

• The Medical Council of New Zealand (MCNZ), which sends a voluntary workforce survey with renewals of annual practising certificates. When contacted by the authors, the MCNZ could not supply information such as psychiatrists' practice intentions, their age distribution, place of birth, practice site, how many undertook their specialty training in New Zealand, or how they divided their working time between the public and private sectors and advised such detail could only be obtained from additional evaluation (personal communication).

In the aftermath of all the health sector reforms of the 1990s, there has been no publicly available data about the socio-demographic and professional practice profile of New Zealand's psychiatrists. Conceivably, pharmaceutical companies could maintain databases of practising psychiatrists, but this would not be readily accessible by investigators and likely to be regarded as commercially sensitive. Furthermore, the limited amount of data on New Zealand psychiatrists would not detail the reasons why psychiatrists choose to work in nonmetropolitan areas, the challenges they face and the factors which might influence them to move to metropolitan areas or even outside New Zealand. In this study we aimed to increase our knowledge of these important facets about the psychiatric workforce in New Zealand.

Method

Questionnaire

A questionnaire was prepared specifically for the New Zealand context by reviewing previous workforce surveys [9–11], consulting with a focus group [12] and then piloting with a group of psychiatrists. The questionnaire is available on request.

Data Collection: The study questionnaire was mailed with a cover letter in March 2001 to all medical practitioners listed in the Medical Council of New Zealand's ‘Psychological Medicine or Psychiatry’ vocational register [13] with a New Zealand mailing address and held a current practising certificate. Data on the following variables were requested:

• Basic demographic data (sex, age group, country of birth, ethnicity, primary language and personal circumstances).

• Professional training (country where basic medical qualification was obtained, principal country of psychiatric training, whether it was in a metropolitan or non-metropolitan setting and types of specialist psychiatric qualifications held).

• Current professional status (principal practice site, private or public sector, subspecialty area and years spent practising psychiatry in New Zealand and elsewhere).

• Practice intentions (expected length of career, reasons for working in New Zealand rather than in other countries and likely alternatives to working in New Zealand).

Psychiatrists were asked to rate a list of reasons as very important, important or not important in their choice to work and remain in either metropolitan or non-metropolitan areas.

Statistical analysis

Chi-squared test and Fisher's exact tests were used to investigate whether demographics, professional training and qualifications differed between psychiatrists in the two types of areas. Logistic regression was used to investigate factors that influenced whether or not a psychiatrist worked in a metropolitan or non-metropolitan area. A repeated measures regression analysis was used to investigate whether psychiatrists had different motives for working in metropolitan and non-metropolitan areas. In these analyses, factors were classified into three categories similar to Kamien and Buttfield's schema [14]: professional (career opportunities, availability of professional support and development); personal (monetary benefits, health status of the psychiatrist); and social (lifestyle, educational facilities for children, recreational facilities, partner's career prospects, proximity to family members).

Results

Sample

The vocational register had listed in its ‘Psychological Medicine or Psychiatry’ section 277 medical practitioners who had both a New Zealand mailing address and a current practising certificate. Since the register's publication date (30 September 2000), six psychiatrists had permanently left the country and five had retired or surrendered their practising certificate. One hundred and fifty-nine completed surveys were returned, giving a response rate from the 266 active practitioners of 59.8%.

One hundred and two (64.2%) were men, 57 (35.8%) women; 69 (43.4%) were born in New Zealand; 144 (90.6%) described themselves as European, 10 (6.3%) Asian, 2 (1.3%) Maori and 2 (1.3%) Pacific Islander. One hundred and forty-two (89.3%) identified English as their primary or first language. Ninety-nine (62.3%) were in a longterm relationship with dependent children, 38 (23.9%) were in a long-term relationship without dependents, 17 (10.7%) were single without dependents and 4 (2.5%) were single parents.

Professional training

Seventy-three (45.9%) obtained their primary medical degree in New Zealand, one (0.6%) in Australia and 83 (52.2%) outside Australasia; 80 (50.3%) trained in psychiatry mainly in New Zealand, 7 (4.4%) in Australia and 72 (45.3%) trained outside Australasia; 149 (95%) trained predominantly in a metropolitan area. Seventy-four (46.5%) held the Fellowship of the Royal Australian and New Zealand College of Psychiatrists (FRANZCP) as a sole specialist qualification; 34 (21.4%) had the FRANZCP together with other specialist qualifications and 51 (32.1%) had non-FRANZCP specialist qualifications. Of the psychiatrists holding an FRANZCP, 85 (78.7%) trained in Australasia and 23 (21.3%) outside Australasia.

Current professional status

One hundred and thirty-six (85.5%) worked for more than 80% of their time in New Zealand's five main metropolitan areas of Auckland, Hamilton, Wellington, Christchurch and Dunedin; 21 (13.2%) practised mainly in non-metropolitan areas and one (0.6%) was not currently working. Of the 156 psychiatrists who specified their fulltime equivalents (FTEs), 107 (68.6%) worked only in the public sector, 11 (7.1%) worked exclusively in the private sector and 38 (24.4%) had a mixed practice.

Subspecialty areas

Most respondents worked in adult general psychiatry (40%) while others worked in psychiatry of the elderly (11%), child and adolescent psychiatry (10%), administrative/research psychiatry (9%), academic psychiatry (7%), forensic psychiatry (6%), consultation-liaison psychiatry (4%), psychotherapy (3%), rehabilitation psychiatry (3%) and other fields of psychiatry (6%).

Length of experience

Nineteen (12%) had practised psychiatry for less than 10 years, 81 (50.9%) 11–20 years, 38 (23.9%) 21–30 years, 17 (10.7%) 31–40 years and three (1.9%) had been in practice for 41 years or more. Eighty-two (51.6%) had spent over 80% of their psychiatric career in New Zealand, 33 (20.8%) has spent 50–80%, 31 (19.5%) 20–50%, and six (3.8%) less than 20%.

Practice intentions

Thirty-seven (23.3%) expected to continue practising psychiatry for less than 10 years, 74 (46.5%) expected to continue working for 11–20 years, 42 (26.4%) for 21–30 years and five (3.1%) indicated that they wanted to practise for 31 years or more. One hundred and fourteen (71.7%) expected to spend nearly all of their remaining career in New Zealand, 22 (13.8%) 50–80% of their career, 11 (6.9%) 20–50%, and six (3.8%) less than 20%.

Reasons for practising in New Zealand

Respondents rated each item on the questionnaire for choosing to practise in New Zealand as unimportant (1), important (2) or very important (3). The most common reasons for choosing to work in New Zealand were that it was a good place to bring up family (mean = 1.41), its good physical environment (mean = 1.4) and availability of recreational activities (mean = 1.1). Other stated reasons were, in order of decreasing importance: proximity to family members (mean = 0.99); low crime rates (mean = 0.72); partner's work (mean = 0.67); low litigation risk (mean = 0.64); professional/collegial support (mean = 0.57); independence of practice (mean = 0.54); ability to practise generically (mean = 0.51); remuneration (mean = 0.26); lower taxation rates (mean = 0.23); and non-salary benefits (mean = 0.21).

Comparison of psychiatrists working in metropolitan and non-metropolitan area of New Zealand

Data was available for 136 psychiatrists working in mainly metropolitan areas and 21 psychiatrists working in mainly non-metropolitan areas (Table 1). Best subsets selection [15] was used to determine which of the demographic and professional factors should be included in a logistic regression model to predict whether or not a psychiatrist worked in metropolitan areas. The final model included as explanatory variables: basic medical degree (whether from New Zealand or not); having the FRANZCP or not; percentage of career spent practising in New Zealand (more or less than 50%). There was an indication that psychiatrists who did not have an FRANZCP were more likely to work in non-metropolitan areas (57% vs. 27%, p = 0.05). Psychiatrists who had spent more than 50% of their professional life in New Zealand were more likely to work in non-metropolitan areas than those who had spent less than 50% of their time in New Zealand (86% vs. 74%, p = 0.02). Psychiatrists who had obtained their primary medical degree outside New Zealand were more likely to be in non-metropolitan areas (81% vs. 49%, p = 0.04).

Table 1.

Comparison of psychiatrists working in metropolitan and non-metropolitan areas

Reasons for possibly leaving New Zealand

Respondents were asked to score reasons that might prompt them to leave New Zealand on a scale of 0–2 (unimportant = 0, important = 1 and very important = 2). The top five reasons were: higher remuneration (mean = 1.35); better professional support and development (mean = 1.26); improved career opportunities (mean = 1.2); being closer to family members (mean = 1.17); and stress/burnout (mean = 1.19). Other causes included: better non-salary benefits (mean = 0.89); lifestyle/recreational activities (mean = 0.86); partner's work (mean = 0.82); lower taxation (mean = 0.74); better educational opportunities for children (mean = 0.65); and health status (mean = 0.46). It is noteworthy that seven (4.4%) of the respondents indicated that they would never practise outside New Zealand and of those who might, Australia was the most popular likely destination.

Factors which influence choice of practice site

A repeated measures regression analysis found that metropolitan and non-metropolitan psychiatrists had different reasons for staying in their chosen site (p < 0.001). Professional factors were rated more important as a reason for staying by metropolitan psychiatrists compared with non-metropolitan. Whereas both groups tended to rate health and economic reasons as unimportant, the distribution of importance of social reasons was similar for both groups (Table 2).

Table 2.

Factors influencing choice of practice area and decision to move area

What might make psychiatrists move

Tewnty-eight (20.6%) of the metropolitan psychiatrists indicated they would never leave for a non-metropolitan area, whereas six (28.6%) of their non-metropolitan counterparts would never leave for a metropolitan area.

A repeated measures analysis found differential importance being placed on various factors that might induce a metropolitan psychiatrist to leave for a non-metropolitan area or vice versa (p = 0.02) (Table 2). Professional development was rated as a slightly less important reason for leaving by metropolitan psychiatrists compared with nonmetropolitan. Personal reasons were more important for the metropolitan psychiatrists than non-metropolitan ones and social reasons were more important for metropolitan psychiatrists.

Reasons why psychiatrists moved workplaces

One hundred and two (75%) of the 136 metropolitan psychiatrists had never worked in a non-metropolitan area, while 28 (20.6%) had done so and left. Twelve (57.1%) non-metropolitan psychiatrists had never previously worked in a metropolitan area, while eight (38.1%) had done so and left. A repeated measures analysis showed different emphasis on various factors as reasons for leaving metropolitan or nonmetropolitan areas (p = 0.002). Table 2 indicates that professional reasons and salary were more important for those who had shifted to the metropolitan areas. Health reasons were about the same for the two groups, while social factors were mixed.

Discussion

This is the first paper that highlights some interesting trends about New Zealand's psychiatric workforce. Most psychiatrists were men (64.2%), in their 40s (45.9% were aged 41–50) and born overseas (56.6%). A majority (50.9%) had 11–20 years of psychiatric experience, most of which was in New Zealand. Less than half the respondents obtained their basic medical qualifications in New Zealand. Other countries that have reported increasing reliance on overseas-qualified psychiatrists include the UK [16], the US [17] and Canada [18], [19] who rely on overseas psychiatrists to deliver adequate mental health services. Of particular note is that of the 72 psychiatrists whose specialist training took place outside Australasia, only 23 (31.9%) held the FRANZCP. Under the current MCNZ guidelines, psychiatrists with overseas qualifications can be included on the vocational register after one probationary year, which may not be a strong incentive for these psychiatrists to obtain the FRANZCP. This situation may be different in Australia where most state medical boards would require overseas-trained psychiatrists to obtain the FRANZCP within a stipulated time before continuation of practice. Finally, most psychiatrists (68.6%) worked only in the public sector.

Selection of work place

Psychiatrists without an FRANZCP as well as those who had spent large portions of their practice time in New Zealand were more likely to be working in nonmetropolitan areas. Non-metropolitan psychiatrists were likely to move to metropolitan areas in pursuit of better career opportunities, whereas metropolitan psychiatrists would move to a non-metropolitan area for personal or social reasons. This finding indirectly indicates that while metropolitan psychiatrists felt professionally satisfied, they might be attracted to work in non-metropolitan areas by personal or social benefits, a possibility that may highlight the need to investigate job satisfaction and burnout among psychiatrists in New Zealand.

Migration trends among New Zealand psychiatrists

Of the respondents, 71.7% wanted to stay in New Zealand for 80–100% of their remaining professional career. This finding is in sharp contrast with the popular perception that most psychiatrists in New Zealand are eager to emigrate, especially to Australia. Higher remuneration, better professional development and improved career opportunities were the most common reasons for wanting to leave New Zealand. Stress and burnout featured less prominently, which is consistent with 72.9% of the respondents wanting to work for 11–30 more years in psychiatry. Senior psychiatrists' ability to retire between ages 55 and 60 due to enhanced pension benefits is cited as the common cause of heavy loss of personnel in the UK [20], whereas New Zealand does not have such a scheme.

Interestingly, psychiatrists chose to work in New Zealand mainly for family reasons, its climate or availability of recreational facilities. The first reason would be consistent with the finding that 86.2% of the respondents were in long-term relationships either with or without dependent children. Psychiatrists who have chosen to work and stay in New Zealand have possibly made a conscious decision of preferring lifestyle to monetary factors. This finding is reflected in respondents ranking remuneration, taxation and non-salary benefits as the least important factors for working in New Zealand. It is also worth noting that psychiatry is reported to be more compatible with normal family life than other medical disciplines [21]. It is therefore possible that psychiatry tends to attract people who place greater importance on lifestyle, though its relative importance in choosing a career may differ between men and women. Female psychiatrists cited ‘amount of patient interaction’, whereas male psychiatrists cited ‘lifestyle factors’ as the primary reason for choosing a career in psychiatry [22].

Respondents stated that better money and professional opportunities would influence them to emigrate. For this group, slightly more than half identified Australia as their preferred destination. This is in keeping with the reported trend of New Zealand doctors preferring to migrate to Australia [23].

Future intentions of psychiatrists in New Zealand

Most of our study sample wanted to stay in the profession for a considerable period. Psychiatrists report higher levels of stress than other disciplines [24]. Storer [20] suggests that the very factors that lead to psychiatry as a career choice also make doctors more vulnerable to stress. This creates a unique difficulty because if individuals vulnerable to stress were to be screened out of psychiatry, valuable qualities such as empathy and sensitivity would also be lost. High stress levels from bureaucracy and interference by managers in clinical decisions [25] have been reported as a common reason for leaving psychiatry as a career or even retiring early in the UK. Less interference from managers or the ability to practise independently was much lower in the list of reasons as to why people chose to work in New Zealand. Possible explanations include being a psychiatrist in New Zealand is not as stressful as in other countries, or New Zealand psychiatrists are unable to stop working any earlier for financial reasons. An Australian study [26] reported that while lifestyle factors were important in attracting psychiatrists to work for rural centres, factors related to administration prompted them to leave. The study also reported that empowerment, recognition and satisfaction were significantly associated with retention of psychiatrists. It is possible that different factors operate for attracting psychiatrists compared to their retention, which is also supported by our findings.

Future recommendations

There is a need to develop standardized definitions for the terms ‘metropolitan’ and ‘non-metropolitan’ in New Zealand. We adopted the Australian Commonwealth Department of Health's Non-metropolitan, Remote and Metropolitan Areas Classification system (‘RRMAC’), so that ‘metropolitan’ referred to any centre which had more than 100 000 inhabitants [9]. Without standardized definitions for usage in New Zealand there is a possibility of inconsistency.

Future work should also examine the issue of geographical maldistribution of psychiatrists in New Zealand. According to the 1996 census data, 57% of New Zealanders live outside its five metropolitan areas [26], whereas 85.5% of our respondents worked mainly in a metropolitan area, which suggests a significant maldistribution of psychiatrists. Similarly, at the time the study was undertaken, the population of New Zealand was 3.86 million [26] giving a national average of approximately one psychiatrist per 14 000 persons. This could well indicate a shortage of psychiatrists compared to other countries [1–3].

Caution is suggested in interpreting the findings of this study and future work should incorporate information on medical registration and its relationship with the location of work. This study focused on vocationally registered psychiatrists, who are able to practise in any area of New Zealand without needing oversight by another specialist psychiatrist. A more complete picture of New Zealand's specialist psychiatrist workforce will need to include information on practitioners with the remaining three types of registration (temporary, probationary and general), which do not allow the same degree of freedom of movement for practising in different areas of the country. It is noteworthy that the Medical Council allows overseas-trained psychiatrists to practise for a maximum of 3 years if the position has been advertised in New Zealand and was not able to be filled by a New Zealand resident doctor. There were 51·temporary registrants on the year 2000 medical register but we do not know whether such doctors predominantly worked in metropolitan or non-metropolitan areas. Similarly, temporary registrants who have worked in New Zealand for at least one year and intend working in a ‘rural or provincial area’, are eligible to apply for probationary registration. The medical register lists probationary registrants in a manner that does not allow the ready identification of numbers working in psychiatry or their place of work. Two other groups who could have been missed include: psychiatrists who may be eligible for specialist registration but choose to remain on the general register and those who have completed their senior trainee year and are effectively functioning in a consultant psychiatrist capacity, but are not yet eligible to be listed on the vocational register. These groups may provide additional information that may have been missed in this study.

Future research should also examine the factors that may affect response rate. Burnout and job satisfaction may have a role to play in this regard and will need to be examined. The impact of location of practice and training background on response rate may also need to be examined. For instance, according to the MCNZ data, even though more than half of the psychiatrists were overseas-trained only one-third of the non-FRANZCP specialists responded in the study. We did not investigate whether working in metropolitan centres had any impact on the response rate.

Finally, our respondents were not asked if having registrars would have any impact on retention. Our previous work found that the absence of registrars was cited as a significant problem by psychiatrists working in non-metropolitan areas [11]. Others have suggested that delegating so-called ‘routine work’ such as form-filling, venepuncture and history-taking, to junior medical staff may be important in better retention [19]. The impact of trainees on retention of psychiatrists could be investigated.

Conclusion

This study has significant implications for those concerned with the recruitment and retention of psychiatrists. Paying attention to the attributes of psychiatrists who choose to work in rural or urban areas may improve retention. For instance, non-FRANZCP psychiatrists and those who have spent large portions of their practice time in New Zealand may be targeted for recruitment in non-metropolitan areas of this country. It is noteworthy that the primary reasons why psychiatrists choose to work in New Zealand are those related to raising family, its climate or availability of recreational facilities. These factors may be worth highlighting in future recruitment initiatives. Psychiatrists looking at relocating to New Zealand for these and other reasons, such as less interference from managers or the ability to practise independently, may be more likely to stay in New Zealand.

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