Attracting psychiatrists to a rural area-10 years on

Context: In rural areas across Australia the recruitment and retention of adequate numbers of medical specialists, including psychiatrists, has been a long outstanding problem. Latrobe Regional Hospital (LRH) has not been exempt. Latrobe Regional Hospital provides public mental health services to a population of over 220 000 across the rural Gippsland region, with little or no access to local private psychiatrists. The equivalent of 11 full time psychiatrists are employed, the majority of whom are international medical graduates (IMGs). Issue: Latrobe Regional Hospital reached a major crisis in 1994, with only one psychiatrist and a large number of vacancies. This led to a focus on the recruitment and retention of psychiatrists in order to improve this essential element of the workforce. In 2006 an internal review of psychiatrist recruitment and retention over the past 10 years was undertaken to gain a better understanding of approaches that worked, those that could be improved and those that required further development and implementation. Elements of the review included aggregation of data from employment records, documented changes to the medical structure, level of professional support provided and the LRH educational program for psychiatrist IMGs. Individual interviews were also undertaken with psychiatrists who have been or are now employed by LRH.

Lessons learned: Between 1994 and 2006 the number of full time equivalent psychiatrists employed by LRH increased from one to 11. Retention rates also improved from an average of 18 months to 4 years.The key elements of this success are seen as: a focus on building individual rapport with new psychiatrists at the time of their recruitment; an extensive and multifaceted orientation program, taking into account cultural background; working to meet individual and family needs, both professionally and within the wider context; a sectorised medical staff structure with both community and inpatient elements; the provision of ongoing educational support with a specific focus on preparing for Royal Australian & New Zealand College of Psychiatrists' fellowship exams.A number of additional issues were also identified that had the potential to further increase psychiatrists' work satisfaction and longer term employment.These included an increased focus on cultural adaptation and professional supervision, as well as additional linkages to city based psychiatrists and services.
Key words: Australia, international medical graduates, medical education, psychiatrists, recruitment, retention.

Context
The Australian rural experience indicates that there is a longterm problem in attracting medical practitioners 1 .In particular, access to psychiatrists in rural areas has been seen as uniformly a major problem 2 .

Difficulties in recruiting
Difficulties in recruiting in the early 1990s led to a crisis in 1994.With just one psychiatrist employed, the service relied on the assistance of metropolitan-based psychiatrists in an outreach model.The number of psychiatrists employed at LRH over the last 12 years is plotted in Figure 1, which demonstrates a gradual increase in numbers.
In 1994, despite extensive advertising in Australia, little or no interest in positions was received.Reasons for the exodus of Australian-trained psychiatrists from the public sector have been described as multiple and coincided with the First National Mental Health Plan and associated reduction in mental hospital beds by 42%.The private sector proved very attractive, with perceived increased control over work, capacity to work one-to-one rather than within a team, and exposure to a broader range of psychiatric disorders 4 .It became essential to give priority to the recruitment and retention of psychiatrists -for the benefit of both clients and staff.A recruitment and retention strategy was implemented in 1995, resulting in an increase of appointments (Fig1).
Success was not achieved overnight, and it came about through a combination of factors.

Profile and publicity
A concerted effort was made to raise the profile and credibility of the service.Presentations at conferences, showcasing of aspects of the model of care, the development of state-wide protocols with the Victorian Department of Human Services, and stronger linkages with other rural mental health services were important aspects.

Establishing Individual rapport
Advertising in international psychiatry journals achieved significant interest from psychiatrist international medical graduates (IMGs) who had specialist qualifications gained outside Australia.The service concentrated on presenting a

Multifaceted orientation program
The transition of psychiatrist IMGs and their families to a new country and culture is important 5 .Assistance was provided with housing, schooling options and getting established in a new environment.
Considerable effort was taken with the induction and orientation of new psychiatrists.While most services have well-developed professional orientation to the organisation, it is equally important to maintain a supportive environment as well as address differences between cultures and countries 6 .Some of the matters discussed include: family structure and values in Australia community values behaviour which is seen as acceptable and that which is not colloquial use of language, especially swearing or slang.

Improving retention rates
By 1997, LRH had full psychiatrist staffing with seven psychiatrists IMGs employed.However retention rates were still relatively low with a number of psychiatrist IMGs passing their fellowship exams and moving to private practice or more senior positions within the public hospital sector.Others moved from Victoria to other Australian states.
Once again, psychiatrist IMGs filled this gap.Word of mouth proved to have an increased impact, with psychiatrist IMGs recruited who were already working in more junior roles within Australia.
Retention of staff is as important as staff recruitment 7 .
Retention rates of psychiatrists employed by LRH improved from an average of 18 months in 1994 to an average of

A review of our performance
Individual interviews were recently undertaken with past and present psychiatrists with a response from 14 out of 19 previously and currently employed psychiatrists.
To be described in more detail in a future article, a number Hospital (LRH) is located within Gippsland, 2 hours from Melbourne, the state capital of Victoria.The Gippsland region stretches from the eastern edge of Melbourne to the far-eastern Victorian/New South Wales border.It has a unique combination of socioeconomic groups and demographic spreads, including urban coastal areas, industrial centres and remote rural towns.Mental health services are provided to approximately 3500 clients per year in a geographical area of over 40 000 km 2 .The LRH mental health model is based on 'Victoria's Mental Health Service -the Framework for Service Delivery' 3 and is aimed at providing accessible care in a least restrictive environment.The service has been divided into three geographical sectors in which there are a total of eight community mental health centres covering adult, aged and child and adolescent programs.The centrally located inpatient services comprise 25 adult beds, 2 child and adolescent beds, 6 secure extended-care beds, and a 20 bed aged mental health unit.In 2006, the equivalent of 11 full-time psychiatrists were employed across the three programs, working within community and inpatient settings.
all potential applicants, including the provision of information packages covering the service and Gippsland.Prompt responses to enquires and providing information on the recruitment process were other important factors in establishing rapport with applicants.Applications received were predominantly from India.The Victorian employment process included: review of the applicant's curriculum vitae by the state chief psychiatrist; registration with Victorian Medical Practitioner Board; and a temporary working visa until fellowship of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) was achieved.The recruitment process was managed within LRH mental health services and took between 3 and 6 months.It commenced with individual telephone interviews, an important element in the process of building rapport.Experience showed that the greater the rapport between the service and the psychiatrist during this long and often frustrating process, the more likely the recruitment would ultimately succeed.Up-to-date knowledge of visa requirements through contacts within the Australian Government Department of Immigration and Citizenship also assisted in faster visa approvals.

4
years 2006 (Fig2).There were a number of important contributing figures.Medical staff structure: The sectorised medical staff structure implemented in 2001 is outlined in Figure 3.The model provides for sector psychiatrists to have responsibility for the overall care of sector clients both in the community and as inpatients, with the further support of medical officers and registrars (doctors appointed to accredited specialist training position or who hold a position designated as such by the hospital).The continuity of patient care and less demanding travel requirements resulting from clear division of responsibilities and shared workloads proved particularly attractive to the psychiatrists.
of themes emerged from these interviews.Initial recruitment and commencement issues were generally viewed very positively.It was suggested, however, that further introductory materials should be supplied prior to commencement with LRH.The official orientation program also came under scrutiny.It was felt that the program was too quick, and not sufficiently in-depth.Additional information and training in leadership, team dynamics and cultural aspects of Australian and Gippsland were also identified as areas for improvement.Professional isolation was highlighted as a concern, with requests received for additional linkages to city based psychiatrists and services.Feedback was also received on the need for increased peer supervision.Conclusion Significant progress has been made in the successful recruitment of psychiatrists to LRH.While the majority of psychiatrists recruited are IMGs, there is now a significant component of Australian trained psychiatrists who are attracted to the service.It appears that the previous situation of low numbers of psychiatrists employed is in the past.In addition, service systems have improved to the extent that the retention rates for recruited psychiatrists have increased dramatically.The key elements of this success can be seen as: a focus on building individual rapport with new psychiatrists at the time of their recruitment an extensive and multifaceted orientation program working to meet individual and family needs, both professionally and within the wider context a sectorised medical staff structure, with both community and inpatient elements the provision of ongoing educational support with a specific focus on preparing for RANZCP fellowship exams.While these achievements can be seen as the result of changes to recruitment processes and the ability of LRH to better meet the needs of psychiatrists, there is still room for improvement.An increased focus on cultural issues, family support, educational opportunities and additional linkages to city based psychiatrists and services are areas that would further increase work satisfaction and, in turn, result in further improved retention rates.