Medical Training Initiative (MTI) Psychiatry Scheme: Online survey of trainees' experience

Yugesh Rai & Mohammed Al-Uzri

Introduction

Health Education England (HEE) runs the Medical Training Initiative (MTI) scheme on behalf of the Department of Health (the Government Sponsor) and is influenced by the Home Office Tier 5 Government Authorised Exchange Visa Scheme¹. The Academy of Medical Royal Colleges is the national sponsor for visa purposes. Major stakeholders involved in this scheme are the GMC and GMC Approved Sponsors (e.g. Medical Royal Colleges), Postgraduate Deaneries/Local Educational Training Boards (LETBs), and National Health Services (NHS) Trusts, with support from the Department of Health.

The Royal College of Psychiatrists (RCPsych) Medical Training Initiative (MTI) Scheme enables qualified overseas psychiatrists to undertake training posts in the National Health Service (NHS) for a maximum of two years (2). The purpose of the scheme is to provide training opportunities for international psychiatrists in the UK to improve capacity as a professional and return home with broad knowledge and experience. Vacant core training (CT3) posts approved by Deaneries/LETBs are offered to eligible international doctors. Thus, the MTI psychiatry scheme can benefit overseas doctors, the NHS and the countries that trained them.

Although the MTI scheme was first established in 2009, the RCPsych only formally adopted the program in 2014. Some lessons were learned from the experience of the scheme in other specialities and provided an opportunity for the RCPsych to develop its own scheme. It developed a selection process for successful candidates and matches them with relevant placements in NHS trusts across the UK. This process takes into consideration the training needs of the overseas doctor and vacancies available in NHS trusts. The MTI Psychiatry Scheme is now in its sixth year and has gradually grown over the years as evidenced by an increase in annual allocation of the training post to 40 placements, a rise in the number of applicants from different regions of the world and an increase interest from employing NHS trusts. However, there are areas for further development in this scheme and there is a need to ensure that it consistently provides a good training experience to international doctors.

Various researches suggest that there are diverse difficulties faced by overseas doctors during their transition into a new country ^3,4. Lack of information about NHS; clinical, educational and work-culture challenges; language and communication challenges; and discrimination challenges were issues experienced by international doctors while initially working in the UK hospital settings ⁵. The College has recognised these difficulties and wanted to understand how these are impacting on the international doctors and what can be done to help them.

Aims

The aim of this survey was to evaluate the trainee’s experience of the MTI psychiatry training scheme and explore difficulties during the training and what can be done to help. The purpose of this survey was to gather feedback on the current implementation of the MTI scheme.

Methods

An anonymous online survey consisting of 28 questions was sent to doctors using SurveyMonkey as part of the RCPsych Annual MTI survey. All doctors enrolled in MTI Scheme were identified through the RCPsych MTI mailing list. The survey was open in November 2018 for one month.

Results

Out of seventy-six, a total of thirty-one trainees completed the survey with a response rate of 40.78%. Most of them (n= 13) were from the age group 31-35 years. The findings of the survey are summarised in Table 1-3.

Table 1: Description of MTI doctors (n=31)

Table 2: Induction, Supervision and Mentoring (n=31)

Table 3: Work experience in MTI scheme (n=31)

Reasons for choosing MTI Scheme

Training opportunities in the UK were considered by three quarters of the respondents for joining the MTI scheme. However, about half of the respondents reported job prospects, recommendation from senior colleagues and college reputation as pull factors.

Clinical and Educational Supervision

Three-fifths of trainees had weekly supervision with their designated clinical supervisor and three quarters (75%) of them rated the quality of supervision as either good or excellent. The majority (93.54%) of them had an educational supervisor and less than half met the supervisor 1-2 times per year. RCPsych has a mentoring scheme to support MTI doctors but half of the trainees (51%) did not have a mentor.

Out of hour support

Less than one-third of the trainees were never forced to cope with clinical problems beyond their competence. However, three-fifths of trainees reported that they always had access to out of hour support and advice.

Challenges encountered

Lack of knowledge of regulatory framework was reported by three-fifths of trainees while working in the UK settings. In addition to that, half of the trainees reported a lack of knowledge of NHS and cultural differences. One third had difficulty regarding multidisciplinary team settings and varied levels of support and training. About 51.61% felt that their clinical training was secondary to service and few reported feeling unsafe, being bullied and being punished.

Discussion

This is the first evaluation of the training experience of MTI psychiatric doctors. This study showed that most of the trainees had good work experience of psychiatry before coming to the UK. One of the undoubted strengths of the MTI psychiatry scheme is the recruitment of international psychiatrists with skills and experience of working in diverse cultural backgrounds and low resource settings. This is one of the potential benefits that the NHS can draw whilst delivering the health care smoothly. The majority of respondents in the present survey cited training opportunities as the main reason for choosing the MTI scheme. Child and Adolescent Psychiatry, Old Age Psychiatry, Addiction Psychiatry and Forensic Psychiatry were the subspecialties that received the highest interest in the MTI post in a 2017 survey ⁶. It is encouraging that most doctors were keen to gain further experience and training in subspecialties that were not readily available in their respective home countries.. A similar finding has been reported in the Royal College of Anaesthetists’ annual MTI survey where the majority chose subspecialties that were poorly developed in their respective countries, e.g. ICU and pain⁷.

Transition to the UK is not a smooth process for overseas doctors and must be supported during this transition phase (5). Lack of knowledge of the NHS, regulatory framework and cultural differences were the challenges faced by most MTI doctors in this study. The RCPsych International Medical Graduates (IMG) conference acknowledged that IMGs face more problems than British counterparts in succeeding in the system and recognised the importance of trainers, the role of employers in developing meaningful induction programmes and giving IMGs additional support and remediation if required⁸. This study showed that most of the trainees had attended local induction in the workplace before starting a job. Induction course content must be relevant and reflect issues concerning overseas doctors ⁹. It is particularly important to remember the specific needs of overseas doctors as they were trained in culturally diverse and low resource clinical settings. Several studies have shown that a structured induction program is a useful way to integrate doctors during the transition to the NHS^10-12. Few trainees missed the local hospital induction as they arrived in the UK months later than expected and the trust could not arrange the training. With this hindsight, RCPsych organises the annual national MTI induction program to the new doctor in this scheme to complement and compensate for any shortcomings in the local hospital induction.

MTI posts should provide the trainee with an opportunity to train in a highly supported environment. Supervisors provide regular support and ongoing feedback during the training. Trainees value the support they receive through supervision, senior and peer support, and the opportunity to work in multidisciplinary team ¹³. It was reassuring to find that three-fifths of trainees had weekly clinical supervision as recommended by the Royal College of Psychiatrists.The quality of clinical supervision was rated as good by 51.61% of trainees and 22.58 % reported as excellent. Most of them had access to out-of-hour support/advice. Supervision is important for continued professional development as international doctors need more support than UK trained doctors ⁹. Unfortunately, few reported serious issues such as being bullied at the workplace and feeling unsafe. A survey of bullying of psychiatric trainees in the workplace reported that it was experienced equally by both IMGs and UK graduates, but IMGs were less likely to report the incident to the organisation¹⁴. It is important to educate IMGs about the mechanisms to escalate this concern for proper action. Besides that, it would also be prudent to include these pertinent issues during the annual MTI induction program to raise awareness among IMGs.

The MTI doctors had identified areas for additional support from the College, trusts, local deaneries, and senior colleagues in the 2017 annual survey⁶. The College took the following steps:

1. Annual MTI Induction Program: Full day induction program is held annually in the Royal College of Psychiatrists’ for new doctors in the scheme. The program is specifically tailored for doctors who are working in the UK for the first time. Highlights of the program include an introduction to the NHS, Good Medical Practice, Psychiatric training in the UK, ‘Person-Centred Care’, resources and support available for trainees and most importantly, communication skills workshop. It also provides an opportunity to meet with other MTI fellows and share experiences and set up informal support networks such as WhatsApp group. Twenty-three doctors attended the MTI induction program in 2019. Not all doctors recruited in the MTI scheme were able to attend the annual induction program because of the variable start date resulting from delay in visa processing. RCPsych could provide support to these IMGs by organizing the induction program two times a year.

2. MTI Mentoring Scheme: RCPsych runs a mentoring scheme and has been offering mentorship to MTI doctors for the past three years (15). Mentors are usually experienced RCPsych members who have volunteered in the mentoring scheme. RCPsych MTI team matches the mentor and mentee who will stay together for the duration of the placement. The current study shows that 50% do not have a mentor. We did not explore the reason for this, but we speculate that as doctors must actively express their interest in participating in this mentoring scheme and this might have shown less engagement.

3. Annual MTI Scheme Survey: Feedback is collected from MTI doctors each year as part of ongoing efforts to improve the RCPsych MTI scheme.

4. Sharing of experiences about the scheme between the trusts: Trust has varying levels of experience regarding the training scheme and the College has been facilitating the exchange of shared experience by the experienced trust to a new host trust.

This survey explored the experiences of doctors involved in the MTI scheme and it would be interesting to know findings from longer-term studies. Longer-term follow-up studies are needed to evaluate the positive impact of the scheme after the doctors return home on completion of the training. It is hoped that invaluable insight gained from the survey can be used to strengthen the scheme as well as provide learning points to other specialities with similar training scheme for international doctors.

Conclusions

This survey provides useful information regarding training experiences in the MTI psychiatry scheme. The first step in making the difference is getting feedback directly from those involved in the scheme. RCPsych MTI Scheme is an evolving program and measures were put in place to address the needs/concerns that emerged from the survey to enhance the training experience of the MTI doctors.

References

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