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| Journal of the New Zealand Medical Association,
13-March-2009, Vol 122 No 1291
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Lack of coordination between health policy and
medical education: a contributing factor to the resignation of specialist
trainees in Fiji?
Kimberly M Oman, Kim Usher, Rob Moulds
The World Health Organization estimates that there is a
global shortage of over 2.5 million health care workers. These shortages are
most acute in developing countries, and are exacerbated by the migration of many
health workers to developed countries. Shortages of health workers and human
resource issues are receiving increasing attention at an international level
because of their link to poor health
outcomes.1,2
The “scaling up” of health professions education
has been proposed as a means to increase the numbers of health professionals in
developing countries.1,3 As a component of
this, in-country or regional postgraduate medical specialist education can play
a role not only in providing a specialist workforce trained in the settings
where they will be spending their professional lives, but can potentially
improve doctor retention by overcoming the need for aspiring specialists to
spend many years training in developed
countries.4
The availability of local postgraduate training can also
potentially serve as an incentive or reward for clinical excellence as well as
for rural service. To date, few studies have been published about postgraduate
programs in developing countries, and these have generally not focused on the
impact of postgraduate training on migration and
retention.5–11
Regional postgraduate specialist training was established in
1998 in Fiji, a small developing Pacific Island nation (see Table 1), in order
to address a continuing dependence on expatriates, as well as a failure of most
overseas-trained Pacific Island specialists to return home. This training
consisted of a 1-year Diploma, followed by an additional 3 years leading to
Masters of Medicine (MMed) specialist qualifications in obstetrics and
gynaecology, paediatrics, internal medicine, surgery, and
anaesthesia.12–15
It was believed at the time that offering training in the
Pacific that awarded a local specialist qualification not recognised elsewhere
would limit migration.16 Nevertheless, within a
few years many doctors who had started training were leaving the public system
to migrate or to enter private practice.
Table 1.
Population17 and health-related
statistics1 for Fiji
The establishment of postgraduate training coincided with a
worldwide period of openness of developed countries to the migration of doctors
from developing countries, and migration was exacerbated in Fiji around the time
of a coup in 2000.
This study was carried out in order to determine which
factors were leading to resignations of doctors from the public sectors, and
whether these factors could be addressed locally. In particular, preliminary
discussions raised the issue that health workforce policy had not fully adjusted
to take into account the existence of local postgraduate training, and that this
could potentially be a factor leading to disappointment and disillusionment
among trainees.
MethodsQuantitative data were collected on all 120 doctors who
undertook training to at least the Diploma level at the Fiji School of Medicine
(FSMed) by 2004. Data on gender, race, highest educational attainment, and
working location as of December 2006 were obtained from enrolment and graduation
records from FSMed, from local specialist coordinators, and from
publicly-available medical registration information in New Zealand and
Australia.
Whereabouts were confirmed for all 66 Fiji doctors (the
experiences of 54 trainees from other Pacific Island countries are not presented
here). These data were analysed using Epi-Info
software,18 with statistical comparisons
utilising Chi-squared testing.
Table 2. Characteristics of Fiji School of
Medicine specialist trainees 1996–2004 (Fiji doctors only, excluding
regional trainees)
Face-to-face interviews were carried out with 47 doctors who
had worked in specialist departments in Fiji, including 9 senior specialists, 2
pre-training specialist registrars, and 36 of 66 who had undertaken specialist
training through FSMed. Interviews took place between April 2004 and September
2006 during four trips to Fiji and three trips within Australia.
The interviews lasted ½ to 1½ hours and were
semi-structured. Doctors were purposively selected for interviewing in order to
obtaining broad representation on the basis of race, gender, specialty choice,
highest educational attainment, and migration status (see Table 2). Due to
geographic scattering, migrants, private doctors and doctors who had not
completed an MMed were underrepresented. Only two doctors (both migrants living
in Australia) declined to be interviewed.
As part of the interviews, doctors were asked to describe
the decisions they made about completing or leaving training, and about
remaining in the public sectors or resigning. The interviews were audio taped,
professionally transcribed and coded into at least one of several dozen codes
utilising QSR-N6 software.19
Analysis was carried out using a constant comparative
method, with emerging themes being tested and refined through returning
repeatedly to interview transcripts. Findings were presented for comment and
feedback to interview participants and other stakeholders at the annual Fiji
Medical Association conferences in 2005, 2006, and 2007.
The principal author (KO), who played a major role in
establishing postgraduate training in internal medicine as part of her
employment at FSMed between 1998 and 2001, carried out all of the interviews.
The implications, benefits, limitations, and potential for bias arising from
this semi-insider status were acknowledged, reflected upon, and discussed with
supervisors during the analysis and interpretive processes.
Ethics approval was obtained from James Cook University and
the Fiji National Research Ethics Review Committee. The funding sources played
no role in the collection, analysis, and interpretation of data, in the writing
of the report, nor in the decision to submit the paper for publication.
ResultsBy 2004, 120 doctors had undertaken specialist training at
the Fiji School of Medicine (FSMed), of whom 66 were from Fiji and 54 from other
Pacific Islands. By the end of 2006, 36 (54.5%) of the Fiji trainees were either
currently working in the public sectors (32) or were training overseas with
stated intentions to return (4). Ten (15.2%) who resigned were still living in
Fiji (mostly in private practice), and 20 (30.3%) were believed to have migrated
permanently (see Figure 1).
Figure 1. Working situations of 66 Fiji
specialist trainees (at Dec 2006)
 Policy and entry into specialist
training—While health policies supported the establishment of
postgraduate training in Fiji,16 and
significantly opened up locally available career options, Fiji doctors reported
that existing policies provided little clarity in regards to what the impact of
training should be in terms of career advancement.
The policies on the early years after graduation remained
unchanged. New MBBS graduates were told that after a 1-year internship, they
would be required by the Ministry of Health to work outside of the major
hospitals, often in a smaller town or rural area. The prerequisites for entering
formal specialist training included working a minimum of three years following
graduation, including one year as a pre-training specialist registrar.
In practice, many more years often elapsed before the
required pre-training specialist posting was offered by the Ministry of Health,
which also controlled the awarding of government scholarships for undertaking
specialist training. A few doctors, however, seemed to be exempted from rural
service and were invited immediately after internship to join a specialist
department at one of the main hospitals.
I would have loved to do
postgraduate training immediately after internship. The idea that we had after
internship was that you have to do 3 years rural attachment before you come back
to the hospital. Somehow that applies to some but does not apply to others. But
I think we need to push to identify people from internship the first year out
and say ‘you need to go here and here’. And then get the career
identified very early on rather than leaving it towards the end, you know when
you're supposed to have specialised and you're starting your postgraduate
training.
The lack of timely advancement into specialist training was
of concern to staff at FSMed, some of whom described a lack of transparency in
how doctors were selected for specialist training. They wondered whether the
lack of clarity about how to pursue specialist careers led to frustration, lack
of hope, and eventually to resignations.
Policy and Masters (MMed)
graduates—The new MMed qualifications allowed specialist status
to be granted 2 years after graduation. Previously, specialist status could be
obtained either through overseas training or through working in specialist
departments for 15 or so years. Specialist status, while allowing limited
private practice for public sector doctors, was separate from and did not
guarantee promotions to senior roles, and there were no written policies in
place in regards to the impact of an MMed on actual career advancement within
the public service.
By 2006, 21 Fiji doctors had been awarded a Masters degree,
of whom 18 (85.7%) were still working in public sector roles (15) or were
temporarily overseas (3). Of the 11 doctors from the first two graduating MMed
classes, 7 of 8 who were working in the public sectors had moved into senior
roles. Three other graduates in this group had either migrated to Australia (2)
or entered private practice in Fiji (1), and described neither having been
promoted in a timely manner, nor having confidence that they would be promoted
in the future.
And there was also a time
when there were a lot of people migrating out of the country leaving their jobs,
so there were a lot of vacancies at that point in time. It was really quite easy
for me to slot myself in, given that I was the only one who was passing exams.
That’s why my promotion relative to most other people has been quite
quick.
I had the sense of getting
nowhere and I felt 6, 8 years down the line and I’m still gonna be just a
registrar. It’s going back and forth and yet the Ministry was not even
recognising the programme itself, so I said ‘Hey, I’ve just got to
get out of this!’
For the 10 doctors who received their MMed qualifications
between 2003 and 2006, only 2 had been appointed to senior posts. Of the other
8, many described their prolonged junior postings as being frustrating given
that their postgraduate training seemed to have no impact on their career
status.
I guess part of the
frustration would be the way the Ministry, how their structure doesn’t
allow for people to progress. If you do self-developmental things, and keep
getting higher and higher recognitions, part of the frustration of that is
recognising that the people who get promoted have no interest in eventually
pursuing further postgraduate training and stuff like that, but by virtue of
years of service...
But I understand there was
an agreement that if you finish your Diploma you automatically become a senior
medical officer...and once you completed your Masters you qualified to go up as
chief medical officer. But because of the fact that we have a lot of expatriates
who were brought in and occupying the higher posts, and the posts are all
occupied so you still have to settle with the medical officer post (lowest
career grade).
It is of some concern that six MMed graduates have
undertaken or were planning to undertake overseas placements. This is because in
the past, the few doctors who have returned or attempted to return to Fiji after
completing specialist training overseas have faced considerable frustrations,
given that no specific policies or procedures were in place then (or now) to
track their status while overseas or plan for appropriate senior roles on
return.
I was tempted to stay away
but it was basically because I didn’t get any response from the Ministry
of Health when I started writing, to say that ‘I’d finished my
specialist training, if there was a job I’d like to come to it’, and
they didn’t respond for 8 months. My story isn’t unique, man, a lot
of people report this story. I suppose I persisted a bit longer than others but
it was just matter of 2 weeks. If that letter hadn’t come, 2 weeks later I
would have taken up a job in England as a consultant.
Policy and Diploma graduates at a decision
point—While most MMed graduates have continued working in public
sectors, the majority of specialist trainees (42 out of 66, or 63.6%) left
training with a Diploma as their highest qualification, and of these, only 13
(31.0%) are still working in public sector roles (see Figure 2).
Figure 2. Working situation by highest
qualification attained (at Dec 2006)
 Over time, Diploma graduates became increasingly aware of
how difficult Masters training was, and concerns were often expressed about the
quality of supervision, the workloads, and the failures to address problems with
low staffing levels in specialist departments. A lack of coordination between
the demands of academic and hospital supervisors was particularly cited as
adding to an already stressful working environment.
It was very difficult and I
guess a lot of people had bent under that, a lot of our registrars...because of
a lack of commitment from our local counterparts, our local supervisors and our
local consultants...what I mean by bent under, is they just can’t cope
with it, the stress is too much. They’ve just given up because they
haven’t found a way out and probably the only way out is get out of the
system so that the system doesn’t destroy you.
In addition to educational concerns, family commitments were
a very powerful driving factor behind the career decisions that Diploma
graduates made. Due to policies that did not serve to expedite entry into
specialist training, many doctors started specialist training a number of years
above the minimum required after medical school, and the majority had started or
were planning to start families.
Both men and women faced challenges related to the
difficulties of undertaking training on top of already challenging jobs. They
often stayed for prolonged periods at junior postings, earning low salaries.
Women in particular struggled to find time to devote to their families at a very
demanding time in their careers.
Men also struggled with a desire to spend more time with
their families, but they particularly mentioned financial stresses related to
supporting young families. Interestingly, there was little difference in
resignation rates between men and women (see Figure 3).
I was so frustrated! Why I
left was, my number one thing was for my family. I thought I wasn’t giving
enough time. I have three kids, so that was my main reason leaving. I’m
not that ambitious, but the main thing is that I have to get my children started
off and then see my husband do something, then for myself.
One of them, he couldn't
cope with his two children, and his wife was a nurse and he had just bought a
house. For them to be able to look after their financial commitments, both of
them needed to work, true. But they had two small children. So then they decided
it wasn't going to work. They wanted to bring up their children properly, so his
wife, he didn't want his wife to work, just to sort of stay home and look after
the children, and that was the main reason he moved to American Samoa.
‘Because I could do that over there.’ And he earned enough to
support them. And pay off his house as well. The money was good. That was the
main reason he left.
The interviews suggested that in Fiji, both female and male
doctors faced a “biological clock”, or perhaps a “family
clock”, which was probably exacerbated by delayed entry into training. The
fact that there were no policies in place to guarantee timely promotions as a
reward for undertaking training (with their associated better working conditions
and higher salaries) made “hanging in there” at times of stress much
more difficult. On the other hand, quick relief was readily available through
local private practice, and while migration posed its own uncertainties,
opportunities to migrate were readily available.
Figure 3. Highest qualification earned and
working situation by gender (at Dec 2006)
 DiscussionThe establishment of postgraduate training in Fiji has
created new conditions and situations that pose both opportunities as well as
challenges. The interviews with doctors who undertook local specialist training
in Fiji suggested that the structures and policies in the public system have not
adjusted to take into account the realities of local specialist training, and
that this may be having a negative impact on retention.
While it is unlikely that additional resources will be come
available in the near future to substantially increase salaries and improve
overall working conditions, there are some changes that could be made in health
policy that may improve the retention and satisfaction of specialist trainees
without large outlays of funding.
Firstly, although this study did not focus on doctors prior
to entering specialist training, overall retention may be helped by developing a
more transparent process of selecting doctors to work in specialist departments.
Available positions should ideally be advertised at least yearly, and include
more predictable intakes of pre-training specialist registrars (at least every 2
years in each specialty).
Potential trainees should ideally be judged according to
merit by a panel with representatives from the Ministry of Health, the Fiji
School of Medicine, and other important stakeholders. In the interest of
rewarding service, priority should given to those who have spend the longest
time working in regional or rural areas.
Because the retention of Masters graduates has been much
greater than for doctors with only a Diploma, interventions should focus not
only on providing career paths for doctors who leave training with a Diploma,
but on retaining as many trainees as possible through to MMed graduation.
Interventions should include improving coordination between
the hospital and the academic components of the training programme, and
supporting the working environment through actively recruiting into established
but unfilled posts in specialist departments. The availability of part-time work
and training may increase the retention of doctors with young families,
especially women.
Because the conflict between family and working roles can be
particularly stressful, the expediting of specialist status and working in
senior roles could provide considerable relief and encouragement. In addition to
earlier entry into specialist training, trainees would likely be encouraged
through receiving automatic promotions both when they receive their Diploma and
their Masters.
Overall, attention to the promotions process should increase
transparency, should reward merit, and should facilitate promotion to senior
postings for Masters graduates. Granting eligibility for specialist status at
Masters graduation (which allows limited private work for public sector
doctors), rather than 2 years later, may provide for welcome and predictable
financial relief.
Finally, specific steps should be taken to plan for the
return of doctors who have undertaken overseas training, whether for full
specialist training or shorter attachments. Retention of these doctors may be
improved by actively tracking their overseas progress and allowing, in some
instances, overlapping senior postings when they return if an expatriate is in a
senior position but has not finished his or her contract.
This study adds to the limited current literature about the
outcomes of establishing local postgraduate training in developing countries,
and has a number of strengths as well as limitations. Interviews were carried
out with over 50% of Fiji specialist trainees, and the exploratory nature of the
interviews allowed for novel or unexpected insights to arise.
A particular strength of the study is the identification of
possible interventions that can be made at a policy level without large
increases in funding, though the potential for success of these interventions is
not guaranteed, and would merit further study. The involvement of the
interviewer for almost a decade in Fiji, as well as her role in helping to
establish these courses is both a strength and a limitation, as it was likely to
have allowed for a deeper understanding of the situations of the interview
participants, but could have potentially lead to some degree of bias.
The under-representation of migrants, private practitioners,
and doctors who left training with a Diploma may also contribute to bias. The
overall narrowness of the study is another limitation, and the experiences of
medical students, new medical graduates, and non-specialist doctors were not
explored. Generalisation to other countries may also be limited.
Doctor salaries in Fiji are arguably “livable”
though modest, so this study may have limited applicability to more impoverished
nations.
This study may provide some insights for individuals and
institutions that will be increasingly called upon to help scale up postgraduate
training in developing countries. It is reassuring that even with disappointing
losses of trainees to resignation and migration, postgraduate training at FSMed
has succeeded in adding 15 Masters-qualified specialists to the public sector
workforce, with three more planning to return from overseas. This compares to
only 5 Fiji doctors with overseas specialist qualifications currently working in
the public sectors.
Health educators need to keep in mind that their
interventions to strengthen medical education take place within a health system,
not in a vacuum. Health policies can have a profound impact on the success or
failure of educational interventions, and failing to advocate for adjustments to
health policy to take into account the existence of new training programs may
undermine such programmes.
On a more personal level, those who support the scaling up
of medical education, especially outsiders, should attempt to develop a full
understanding of the stresses their students are facing.
“Survival of the fittest” approaches are
probably inappropriate or counterproductive in situations where many doctors end
up dropping out and then resigning from the public sectors, often to migrate.
Compassionate approaches based on genuine understanding, especially if coupled
with a willingness to be an advocate for trainees with government departments
and funding bodies, may also lead to improvements in retention and satisfaction,
and ultimately to stronger health workforces.
Competing interests: I, Kimberly Oman
(principal author) have the following conflicts of interest: I worked at Fiji
School of Medicine (FSMed) from 1998–2001 and was employed initially by
the FSMed and was later by AusAID through the Royal Australasian College of
Surgeons, which was contracted to establish postgraduate training in Fiji. Part
of this study was funded by consultancy fees from the Royal Australasian College
of Surgeons in 2002 for two follow-up visits to oversee the progress of the
postgraduate training in internal medicine. Neither the FSMed as an institution
(apart from individuals as co-authors or supportive colleagues) nor AusAID had
input into the planning, data collection, analysis and interpretation of data,
in the writing of the report, nor in the decision to submit the paper for
publication. I have no other conflicts of interest to declare.
I, Robert Moulds, have the following conflicts of
interest: before being appointed Professor of Medicine at the FSMed, I was the
external advisor for the establishment of the internal medicine component of the
AusAID-funded postgraduate program at the FSMed. I have no other conflicts of
interest to declare.
I, Kim Usher, have no conflicts of interest to
declare.
Note: This article forms part of the
NZMJ's contribution to the International Joint Special Issue on scaling
up training and education of health workers, a collaboration between over 20
health-related journals to publish on a common critically important theme, led
by the journal Human Resources for Health (www.human-resources-health.com)
and the WHO department of Human Resources for Health. For more information,
please see the website.
Author information: Kimberly M Oman, Senior
Lecturer in Medicine, James Cook University School of Medicine, Townsville,
Queensland, Australia; Robert Moulds, Professor of Medicine, Fiji School of
Medicine, Suva, Fiji; Kim Usher, Professor and Head of School of Nursing,
Midwifery and Nutrition, James Cook University, Townsville, Queensland,
Australia
Acknowledgements: We thank staff at the
Fiji School of Medicine for their assistance, in particular the Deans during the
course of the study: Wame Baravilala, David Brewster, and Eddie McCaig. We also
acknowledge Rob Gilbert, Craig Veich, and Richard Hays who provided supervisory
support for this PhD study. Above all, we would like to thank the study
participants who generously gave of their time to be interviewed.
Correspondence: Dr Kimberly Oman, Senior
Lecturer in Medicine, James Cook University School of Medicine, Townsville,
Queensland 4811, Australia. Fax: +61 (0)7 47961271; email: kimberly.oman@jcu.edu.au
References:
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