Mariana Pinto da Costa

Becoming a psychiatrist in Europe: the title is recognized across the European Union, but what are the differences in training, salary and working hours?

The professional qualification as a psychiatrist is automatically recognized across Europe if a national training program fulfils the minimum requirement of four years of training duration (1,2). This is applicable to all 28 European Union (EU) member states, as well as to other countries of the European Economic Area, such as Norway and Switzerland (2). However, what is equivalent on paper may be not in practice: patients and hospital staff increasingly encounter doctors with different educational backgrounds due to the open European labour market and the mobility of trainees and psychiatrists. In 2014/2015, the European Federation of Psychiatric Trainees surveyed training in psychiatry by a questionnaire directed at representatives of national psychiatric trainee associations. Except Cyprus, Czech Republic, Latvia, Luxembourg and Spain, all EU countries were covered. A medical practitioner who undergoes postgraduate training in psychiatry and qualifies as a specialist is called a psychiatrist. Only in the German speaking countries, i.e. Austria, Germany, Switzerland and Liechtenstein, the specialist holds the title of “psychiatrist and psychotherapist” (2), even though training in psychotherapy is a mandatory part of psychiatric training in most European countries (3). Although skills in psychotherapy are widely considered essential for psychiatrists, the number of patients to whom trainees are required to deliver psychotherapy varies and can be as little as zero, as in Estonia (4). In some countries, e.g. the Netherlands, child and adolescent psychiatry is a subspecialty of “adult” psychiatry. In other countries (25 out of 31) it is a separate specialty with up to 600 trainees (as reported from UK). However, only in Belgium the title specifies that a psychiatrist is specialized in adults (“psychiatrie de l’adulte”) (2). A title such as “general psychiatrist” (awarded in the UK) could help differentiate subspecialties and underline the balance of technical and non-technical elements of care (5). In order to match the EU minimum requirement, training duration needs to be four years or longer. The maximum required training durations are seven years in Ireland and six years in Austria, Finland, Switzerland and the UK. Training is not nationally standardized in four out of 31 countries (Belgium, Finland, France and Greece), underlining the challenge of establishing a single, unified European exam. In some countries it is required to rotate in a university hospital (six months in France) or a psychiatry ward in a general hospital (six months in Greece), or to spend twelve months in another hospital (Switzerland), pushing trainees to switch workplace. Outpatient care is strongly enforced in Finland, where half of the training has to take place in outpatient care. Overall, national curricula are still mainly defined by total duration and duration of rotations in (sub)specialties, despite the benefits of competency-based training (which may also facilitate a pan-European exam). Appropriate working conditions, including salary and working hours, are essential for high-quality clinical training. Trainees in EU countries work 35 (Bulgaria) to 65 hours (Malta, including on-call hours) per week. Non-EU countries are characterized by less working hours: 35 hours per week in Belarus, Russia, Serbia and Ukraine. Income varies from 90€ per month in Ukraine to >4,000€ in Switzerland, i.e. in some countries trainees earn 44 times more than in others. The top-five countries in terms of average monthly salaries, mostly including on-call hours, after tax deduction are Switzerland, Sweden and the UK (≥4,000€), Norway (3,400€) and Germany (2,900€), while the lowest monthly salaries are paid in Ukraine (90€), Bulgaria (140€), Belarus (150€), Russia (150-500€) and Romania (400€). In Portugal (1,200€) it is common for trainees to spend a period abroad, during which they continue to be paid by their institution. Trainees in Belgium are paid (1,900-2,400€ per month) by their supervisors, which may cause conflicts of interest. Notably, not all aspects of training (especially parts of the psychotherapy curricula) are free of charge for trainees (4), further reducing their spendable income. In most countries (17 out of 31), too few medical practitioners choose psychiatry as their specialty, yet initiatives to increase recruitment are lacking. As a consequence, in 16 countries, not all vacant positions are being filled, and only in very few countries (e.g., Greece) demand for training positions exceeds openings. Thus, the characteristics of psychiatric training vary widely across Europe, despite an open labour market where specialists frequently work in foreign countries. The fact that the qualification of psychiatrists is equivalent throughout Europe should stimulate international cooperation when re-designing training curricula. Guidance and support by international organizations such as the European Federation of Psychiatric Trainees (6), the European Psychiatric Association (7), the European Union of Medical Specialists (8), the World Health Organization and the WPA are crucial in order to facilitate harmonization of curricula. To improve local implementation, an international system of training programme inspections should be established.

Equal access for all? Access to medical information for European psychiatric trainees

Access to medical information is important as lifelong scientific learning is in close relation with a better career satisfaction in psychiatry. This survey aimed to investigate how medical information sources are being used among members of the European Federation of Psychiatric Trainees. Eighty-three psychiatric trainees completed our questionnaire. A significant variation was found, and information availability levels were associated with training duration and average income. The most available sources were books and websites, but the most preferred ones were scientific journals. Our findings suggest that further steps should be taken to provide an equal access to medical information across Europe.

Associations of early career psychiatrists worldwide: history, role, and future perspectives

In response to the multitude of scientific, clinical, and social challenges that psychiatry faces today and the challenges in professional development that go along with them, several associations of early career psychiatrists (ECPs) have been created around the globe in recent years. Participation in these associations promotes local, national, and international sharing of experiences and provides advocacy platforms for improvement of training and working standards. Furthermore, associations of ECPs contribute to networking and to decreasing professional isolation. This paper provides an overview of the aims, structure, and organization of some of the most important international associations of ECPs. Some of the first national associations of ECPs will also be described.

Outcomes of Different Methods for Analysis of Biliary Brush Cytology and of Factors Associated with Positive Diagnosis in an Age-Dependent Retrospective Review

Background and Aims: Brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is the most frequently used strategy for obtaining a tissue sample from an indeterminate biliary stricture. A recent study reported that age is a factor associated with positive yields, but further analysis of how age influences the results was lacking. We aimed to evaluate clinical effectiveness of biliary cytology and prognostic factors for a positive outcome, especially age. Methods: This study was a single-center, retrospective, clinical study of 77 consecutive patients who underwent brush cytology during ERCP to obtain a diagnosis of an indeterminate biliary stricture. We compared 2 routine cytology techniques: A (smear); B (centrifugation of the cytological material collected and the cut-off brush + cell block when sufficient amount of material was available). The data were collected aiming to compare the accuracy of the different techniques used and the prognostic factors affecting the outcome, with a particular focus on age. The yield for brush cytology was compared with the gold standard defined as either definitive histology or the long-term clinical course. Results: The overall accuracy of the 2 used methods was 75.3%. Sensitivity was 52.5%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 66.1%. Although not statistically significant, there was a trend toward accuracy for method B compared with method A (80.4 vs. 65.4%; p = 0.153). Multiple logistic regression analysis showed that younger age was the only independent prognostic factor associated with a positive diagnosis (OR 0.95; 95% CI 0.90–0.99; p = 0.039). Receiver operating characteristic curves for age yielded an area under the curve value of 68.2%. On the basis of the Youden index, 69 years was found to be the optimal cutoff for age. Conclusions: In this series, the accuracy of routine biliary brush cytology was not equal for all methods and ages; in particular, younger patients (below 69 years) tended to have a higher probability of a correct diagnosis.

[Suicidal Behavior among Portuguese Psychiatry Trainees: Comparison with the European Situation].

Introduction: The aim of this paper was to assess the prevalence of suicide ideation and attempts in Portuguese psychiatry trainees (adult and child and adolescence), and compare the data with the general population and other European countries. Material and Methods: A structured and anonymous questionnaire was sent by email to 159 portuguese trainees of adult psychiatry and child and adolescence psychiatry with questions about personal history of suicidal ideation and suicide attempts, as well as family history of suicide attempts and completed suicides. This is part of the BoSS Study (Burnout Syndrome Study) performed in 21 countries worldwide. Data was analysed in SPSS v.19. Results: From the inquired population, 62 trainees (40,3%) partially responded, and 46 (29%) were complete responders - these entered the final analysis. There was a ratio of 2:1 (female:male) and a mean age of 29 years. The suicidal ideation was present in passive form in 44% and in active form in 33%; also, 4.3% of respondents had previous suicide attempts. In first degree relatives, 22% had attempted suicide and 13% completed suicide. Discussion: The results are worriying and may be associated with some factors to which this population is exposed. Conclusion: It is necessary further research to better understand this phenomenon, its causes and potential modifiers.