Anti-migrant sentiments,allostatic load and the welfare of the Australian psychiatric workforce

Abstract

We propose that anti-migrant sentiments (AMS) are a stressor to which psychiatrists and psychiatric trainees in Australia are particularly susceptible, given the significant proportion of specialist international medical graduates that comprises the Australian psychiatric workforce. We conceptualise this stressor as a potential contributor to allostatic load (AL) – a term used to describe multi-system physiological dysregulation in individuals exposed to chronic stress. We illustrate how the AL concept can be utilised to understand and address how AMS can have tangible biological impacts on psychiatric doctors in Australia and also give rise to broader workforce implications.

The medical component of the contemporary Australian psychiatric workforce relies heavily on psychiatrists and psychiatric trainees who are first- or second-generation migrants. In this piece, the terms “migrant” and “migrant background” pertain to those who are first- or second-generation immigrants to Australia and we include international medical graduates (IMGs) in this definition. While the exact number of migrant psychiatrists and trainees has yet to be quantified, it has been noted that a sizeable proportion of the Australian psychiatric workforce consists of international medical graduates. A cross-sectional study examining the Australian psychiatric workforce identified that, in 2022, specialist international graduates comprised 37% of the nation’s psychiatrists. ¹ Therefore, it is highly plausible that the total proportion of psychiatric doctors who are of migrant background in Australia – per our definition – is significant.

We propose that psychiatrists and trainees of migrant backgrounds are vulnerable to anti-migrant sentiments (AMS) and we conceptualise these as stressors and contributors to allostatic load (AL). AL is a term that refers to the cumulative burden of physiological stressors on biological systems. Here we define AMS as any sentiments – espoused by individuals, groups or organisations – which either directly or inadvertently alienate migrants in Australia. Through the lens of the AL concept, we posit that AMS are a stressor that affects the health and wellbeing of psychiatric practitioners of migrant backgrounds. Thus, we propose that AMS, through heightened AL, could negatively affect psychiatric workforce capacity.

AMS in Australia

AMS are not new phenomena. In the 20th Century, prejudice was directed towards those of Greek and Italian heritage following waves of migration from these countries after the Second World War. ² In more recent times, there has been growing evidence of AMS in Australia that have sought to either directly or inadvertently alienate those of Asian, African and Middle Eastern heritage. ² Migrants have also been subjected to religious discrimination, including antisemitism, in healthcare settings. ³ While not always overt or tangible in the workplace, AMS may contribute to a perceived xenophobic atmosphere which migrant psychiatrists and trainees may encounter through exposure to news, social media or in their personal lives.

Furthermore, migrant members of Australia’s psychiatric workforce may be subjected to more conspicuous AMS in the workplace through direct interactions with colleagues and patients. An emerging literature base, primarily focusing on the experience of IMGs, indicates that doctors of migrant background in Australia may be significantly affected by AMS in their workplaces.^4–7 A 2023 scoping review found that IMGs perceived that they were subjected to racially insensitive comments in workplaces across a range of studies conducted in high-income countries. ⁶ A subsequent mixed-methods study, which included a cross-sectional survey, found that 133 of 208 (63.9%) IMG respondents felt discriminated against while working or attempting to work in the Australian medical workforce. It was found in the qualitative component of this study that sequelae of this discrimination included deleterious effects on physical and mental wellbeing. ⁴ This association between adversely-impacted wellbeing and perceived discrimination against IMGs in Australia has also been supported by quantitative data. ⁵ We propose that the ways in which AMS affect the health of migrant practitioners can be conceptualised in terms of AL.

The concept of AL

AL refers to the physiological load placed on the body in response to chronic repeated stressors. Over time, repeated stressors cause recalibration of homeostatic setpoints; a process known as allostasis. In turn, through repeated allostasis and increased disruption to homeostatic setpoints, physiological systems become taxed even further, thereby leading to AL. AL is reflected in multi-system dysregulation and can lead to the emergence of “high risk” physiological states. Subsequently, protracted and elevated AL leads to pathological endpoints, which results in adverse physical and mental health outcomes. ⁸

Stress physiology is heavily implicated in the pathway that lies between the points of allostasis, AL and the emergence of pathological states. Primary stress mediators, such as cortisol and epinephrine, which are released due to the activation of neuroendocrine axes in response to stressors, drive a cascade of processes which increase AL. Under or over-production of these mediators causes compensatory activity, which leads to secondary outcomes that manifest as dysregulation across physiological systems. Eventually, increased AL leads to the emergence of tertiary outcomes, which are pathological states that arise from physical illness or psychiatric disorders. ⁸ It is pertinent to note that AL can be algorithmically calculated through an index of stress biomarkers spanning multiple biological systems. Such measurements can allow for operationalisation of the AL concept in both research and clinical contexts. ⁹

AMS, AL and workforce implications for migrant psychiatrists and trainees

We propose AL acts as a conduit between AMS and negative workplace implications for migrant psychiatrists and psychiatric registrars in Australia (see Figure 1). Previous works have examined the associations between racism and xenophobia – common themes which underscore AMS – and increased AL. Increased AL in the context of racial discrimination has been associated with adverse health sequelae. ¹⁰ Increased AL and adverse health outcomes have, in turn, been associated with tangible workforce implications. ¹¹ We propose these are relevant to the workplaces of migrant psychiatrists and trainees in Australia.

Figure 1.

Proposed pathway linking AMS to adverse occupational consequences via AL.

Racism and xenophobia, which are directly or indirectly encountered by healthcare workers of migrant origin in Australia, often contribute to AMS. These factors have been directly implicated as stressors which cause repeated and protracted activation of neuroendocrine axes in individuals belonging to ethnic minority populations. ¹⁰ In these populations, such overactivation of stress mediators has been associated with adverse health sequelae (or tertiary outcomes as per the AL model). Such outcomes associated with racism and xenophobia can include: cardiovascular disease, increased metabolic risk, higher levels of oxidative stress, mood disorders, anxiety disorders and even psychotic disorders. ¹⁰ It is also pertinent to consider how such AL-associated adverse health sequelae may affect workplace performance. A number of studies have shown deleterious impacts in the health of workers with respect to occupational performance. Increased AL has been shown to be associated with work-related outcomes such as exhaustion, burnout and poor self-perceived levels of health among workers. ¹¹

Migrant members of the Australian psychiatric workforce may be vulnerable to the effects of AMS. Such vulnerabilities may lead to the AL-mediated health disparities seen in minority groups experiencing racism and xenophobia. ¹⁰ Even without the added stressor of AMS, migrant psychiatrists and registrars often have to negotiate the stressors of acculturation, work-life balance, clinical demands, administrative duties, research and/or continuing professional development requirements. Other stressors unique to the IMG experience in Australia may include lack of supervisory oversight, accreditation processes, additional examination pressures, visa-related issues and differential career progression compared to non-IMG counterparts. ⁷ AMS could increase the cumulative burden of these unique stressors and AL in these individuals. Such increases in allostatic burden would further predispose psychiatric doctors of migrant background to adverse workplace outcomes including impairments in productivity, increased absenteeism and workforce attrition and retention issues. These outcomes could lead to adverse events in patient care throughout Australian mental health systems, which are already strained by elevated rates of burnout and medical workforce shortages. ¹² Such adverse outcomes could create a self-reinforcing cycle, whereby migrants working in a strained system are at risk of further compounded AL through increased workplace stressors (see Figure 1).

While we have proposed a plausible biological pathway between AMS and adverse outcomes among migrant practitioners, it is important to acknowledge heterogeneity within this subset of the Australian psychiatric workforce. Migrant psychiatrists and registrars may differ substantially in factors such as their seniority, visa status, professional standing and access to peer or community supports. We speculate that such points of difference could moderate the impact of AMS on AL and occupational outcomes. Accordingly, certain cultural and resilience factors may be protective, whereas more inexperienced, visa-dependent or isolated practitioners may be at higher risk of AL-related adverse outcomes.

Potential ways forward

There are number of measures which could be implemented to mitigate the AL-related sequelae of AMS when it comes to migrant members of the psychiatric workforce in Australia. Suggested ways forward are outlined in Table 1. Ultimately, stakeholders should aim to move beyond first-line measures such as education and raising awareness about the effects of AMS. It is imperative that systemic reforms akin to those suggested in Table 1 are implemented to promote respect and inclusion of all members of the diverse psychiatric workforce. Collectively, efforts leading to workplace reform and further academic enquiry should ensure that AMS do not jeopardise the important contributions of migrant psychiatrists and psychiatric trainees in Australia.

Table 1.

Suggested priorities and interventions to mitigate against the effects of AMS on psychiatrists and registrars of migrant background

Priority domain	Level of intervention	Proposed strategy	Intended outcome
Advocacy	College/health service	Health services adopt explicit advocacy positions affirming workplaces free of AMS.	Establishment of a normative standard across health organisations that AMS are unacceptable in the workplace.
Workplace reform	Health service	Embed educational programs within health services on the effects of AMS on health and wellbeing.	Increased awareness among staff of AMS and their consequences, supporting a culture of prevention.
Workplace reform	Health service	Develop peer support networks and accessible reporting structures for situations where AMS become problematic.	Individuals experiencing AMS have clear pathways to support and recourse, reducing harm and improving safety.
Research	Workforce/individual practitioners	Conduct empirical studies measuring AL in migrant psychiatrists and registrars, co-designed with migrant workforce members and those with lived experience of AMS.	Quantified understanding of the impact of AMS on stress biomarkers and AL, generating an evidence base to support further intervention.

AMS; anti-migrant sentiments. AL; allostatic load.