Flying solo in Myanmar: case study on challenges and important lessons learned by an early career psychiatrist in a district setting

Abstract

The transition from trainee early career psychiatrist (ECP) to independent practitioner can be challenging. Upon completion of training in well-equipped academic settings, an ECP from Myanmar is required to serve in a divisional hospital for at least 3 years. Significant challenges are faced by ECPs practising solo in divisional hospitals, including inexperience in administrative aspects, lack of future-proof training, scarcity of resources and facilities, struggles in the provision of holistic biopsychosocial treatment, work–life imbalance, and limited career advancement and access to continuous training. The solutions tried thus far include the incorporation of information and communication technology in training, gathering support and distant supervision from both local and international settings, and task shifting. Bigger challenges are often rewarded by faster growth, and difficult times stimulate creative solutions. The sacrifice of these solo ECPs has significantly improved the mental health service of Myanmar district regions.

The recognition of a distinct group of ‘junior psychiatrists’ by the World Psychiatric Association (WPA) during the World Congress of Psychiatry 1999 was a pivotal moment in psychiatric training,¹ allowing psychiatrists to grow and gain more experience before taking up the full role of a consultant. The term ‘early career psychiatrist’ (ECP), adopted by the WPA, includes trainees in psychiatry and new psychiatrists within 7 years of graduation.² This term is significant as it recognises that the transition from trainee to independent practitioner can be challenging and comes with certain tasks, including but not limited to moving toward community mental health, engagement with public media, active participation in scientific research and active recruitment of new blood into psychiatry.³ Competency in psychotherapeutic skills is also another realm that requires further development and training, as psychiatrists are the mental health professionals who can ensure patients receive optimal biopsychosocial treatment.⁴

In low- and middle-income countries, including Myanmar, resource limitations and the different landscape of practice pose significant challenges to ECPs. According to an unpublished lecture by the president of Myanmar Mental Health Society in 2019, the numbers of mental health professionals in Myanmar were as follows: 238 psychiatrists, 286 psychiatric nurses, 11 psychiatric social workers, and eight mental health-trained occupational therapists. These mental health professionals work in two mental health hospitals, two drug treatment hospitals, 46 district general hospitals with mental health facilities and 75 drug treatment centres. ECPs have an important role in district hospitals with a wide coverage area. In this article, the authors will discuss the solo practice of Myanmar ECPs in district settings.

Postgraduate psychiatry training in Myanmar

In Myanmar, the training of psychiatrists is undertaken by the medical faculty of four universities: the University of Medicine 1, Yangon; the University of Medicine 2, Yangon; the University of Medicine, Mandalay; and the University of Defence Services Medical Academy. The training programme lasts for 3 years, and the delivery method includes classroom teaching and clinical attachments. The title of Master of Medical Science (Mental Health) is conferred on successful candidates upon passing the national final joint examination. An ECP is required to serve in government hospitals for 5 years, including 2 years of practice under the supervision of senior consultants and professors in central hospitals, and an additional 3 years in a district divisional hospital. There is a total of 14 divisions, each of which has at least one 200-bed divisional hospital with psychiatric services. Given the scarcity issue, most of those divisional hospitals are manned by only a single psychiatrist. The transition is particularly significant if the ECP moves from a well-supported academic setting to become the only psychiatrist taking care of the mental health of one region. The adjustment, stress and responsibilities are tangible.

Challenges faced by ECPs

The first challenge is the administrative aspect of mental health services. Exposure to different administrative aspects of psychiatry is available during training, although it is mostly theoretical. Upon being posted to a divisional hospital, an ECP is expected to embrace an administrative role for the divisional mental health services. The expansion of services or initiation of new services in the community is challenging, as the tight schedule for hospital-based clinical work consumes the majority of the solo ECP's time. In addition, the sheer number of referrals from other disciplines limits the ability to set up a liaison service; hence, consultation services are the more viable option.

Certain future-proof skills are not given adequate emphasis during training in the academic setting; these include negotiation skills with the administrator, interaction with the medicolegal system, management of media, leadership in the reformation of mental health, and innovation and flexibility in problem-solving. Nevertheless, an ECP is expected to be the leader of divisional mental health in all these aspects upon posting.

In addition, the settings of divisional hospitals are notably different from the academic setting of a university-affiliated hospital. In a divisional hospital, facilities and resources for mental health are significantly limited. Hence, an ECP is expected to optimise mental healthcare using the limited resources available to them, which may mean that standard textbook practice is not applicable all the time. For example, patients who require clozapine or lithium treatment need to purchase it from a pharmacy outside the government hospital, as these medications are not provided by government hospitals. Sophisticated investigations, such as magnetic resonance imaging, are not accessible to all the divisions. The logistics of sending patients to the nearest hospital is tricky because of the long travel distance and also issues with transport availability.

The provision of psychotherapy is another important gap in services. There is a lack of clinical psychologists. Also, most ECPs are not trained to perform psychotherapy as it is not a requirement for the training programme. Hence, divisional mental health services rely heavily on physical therapy, including both pharmacotherapy and electroconvulsive therapy (ECT). ECPs receive training on ECT during their rotation in the brain stimulation unit in Yangon, which is led by three senior consultant psychiatrists. Nevertheless, there is no formal certification or credentialing procedure for ECT, and the provision of ECT services is limited to certain divisional hospitals. In addition, the facilities for recovery-based psychiatric treatment are scarce, and there is a lack of well-trained occupational therapists and employment specialists.

Solo practice means an extremely high workload and long working hours. As a result, work–life balance is a significant issue in Myanmar, an experience shared by other developing countries. Most ECPs from divisional hospitals are continuously on call; this places a tremendous strain on the physical and psychological health of an ECP. When the solo psychiatrist is on medical or maternity leave, there will be no psychiatrist for that divisional hospital until he or she has returned to work.

Other concerns for ECPs include an uncertain future and unclear career pathway. Career advancement in Myanmar usually includes enrolment in PhD study, although this is highly dependent on the availability of posts at the university hospitals. On the other hand, access to continuous training can be restricted, as most conferences, workshops and courses take place in the big cities. The restrictions are due to logistic issues and the difficulty of getting a covering psychiatrist.

Important lessons learned

Creativity and innovation can help when there are limited resources. Advances in information and communication technology have certainly improved the potential of distance learning. The accessibility of free online resources has made continuous self-improvement and updates possible for doctors serving in districts and remote regions of Myanmar as long as there is an internet connection. On the other hand, distant supervision from senior consultants by phone call is a viable option for clinical and administrative issues. This is a form of telepsychiatry which has been harnessed for distant clinical supervision in neighbouring countries of Myanmar.⁵

International peer support is another important resource for personal development. The Young Asia Pacific Psychiatrist Network (YAPPNET) is an initiative of the Pacific Rim College of Psychiatrists that aims to optimise resources for regional developing countries. It fosters collaborative research and peer-supervision networks that can potentially complement the support gap. Communication and learning from peers are facilitated by a Google Group^TM with the name of YAPPNET, as well as a WhatsApp^TM group and discussion through virtual platforms. This model of learning and peer support has unlimited potential to be expanded, given its low cost and ease of maintenance, as shown in the case of a neighbouring country of Myanmar.⁶

Task shifting is another solution to increase human resources tackling community mental health problems. Physicians and doctors from other disciplines in Myanmar have received some training on the management of non-complicated mental health conditions, and they can prescribe most psychotropic medications, including antipsychotics and antidepressants, either on their own or through distant consultation. Currently, Myanmar is reviewing its narcotics laws to include more social rehabilitation programmes as part of the treatment of substance use disorders instead of incarceration. The Ministry of Social Welfare has been providing training to health volunteers, which consists of patients preparing for such social rehabilitation programmes.

Conclusion

Bigger challenges are often rewarded by faster growth, which will lay a foundation for competent and often inspiring psychiatric leaders to emerge in the future. By recognising the current limitations and difficulties, different solutions can be brainstormed through creative and innovative approaches, particularly through policy changes and training. Ultimately, the sacrifice of these solo ECPs has significantly improved access to mental health services for the betterment of the community in district regions of Myanmar. With an increasing number of ECPs in Myanmar, the efforts made to narrow the gap have been fruitful.