Psychiatric Bulletin (2006) 30: 430-431. doi: 10.1192/pb.30.11.430
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 430-431
© 2006 The Royal College of Psychiatrists
Refugee doctors as doctors’ assistants in psychiatry
Julia M. A. Sinclair, Honorary Consultant in Psychiatry and MRC Special Training Fellow in
Health Service Research
Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, email:
julia.sinclair{at}psych.ox.ac.uk
Abdul Hameed Latifi, Senior House Officer in Psychiatry
Abdul Waheed Latifi, Doctor’s Assistant
Warneford Hospital, Oxford
Declaration of interest
None.
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Introduction
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Refugee doctors differ from other international health professionals in
that most left their country of origin under duress, rather than being part of
the induced migration of many healthcare workers from low- to high-income
countries. There are now over 1000 such doctors registered with the British
Medical Association Refugee Council voluntary database of refugee and
asylum-seeking doctors (British Medical
Association, 2006). Having obtained refugee status (or indefinite
leave to remain), many wish to use their skills within the National Health
Service (NHS) and contribute to their host country. However, they need to
obtain the requisite qualifications (i.e. 70% in the International English
Language Test and passes in both the written and clinical parts of the
Professional and Linguistic Assessment Board) before being registered with the
General Medical Council. They also need to gain an understanding of the
culture and context of medical practice within the UK, as well as good
references, if they are to compete successfully for training posts with UK
graduates and other international medical graduates. The most recent figures
available (September 2005) show that only 77 of those registered with the
database are currently working in the NHS and 207 doctors have the required
accreditation but are not yet employed
(British Medical Association,
2006).
The British Medical Association, General Medical Council and some of the
Colleges recognise the potential of this group of doctors and encourage ways
to support them to overcome these initial hurdles
(British Medical Association,
2006). Refugee doctors are dispersed across many regions of
England, as well as Scotland and Wales
(Butler & Eversley, 2005),
but opportunities for paid, supported clinical work while studying are often
sporadic and based primarily in the larger conurbations.
Psychiatry is often a rudimentary specialty in the countries of origin of
many refugees, yet their experiences of persecution within their home country,
forced migration and marginalisation by society in this country may give many
refugee healthcare professionals insights that would be valuable within
psychiatric practice. However, without sufficient exposure to psychiatry a
career in this specialty is unlikely to be considered and a potential
opportunity for recruitment lost.
In response to the European Working Time Directive requirement to reduce
doctors’ hours (Department of Health,
2002), as well as recommendations that junior doctors should not
be responsible for carrying out routine investigations such as
electrocardiography and phlebotomy (Royal
College of Psychiatrists, 2003), Oxfordshire Mental Healthcare NHS
Trust agreed to the creation of ‘doctors’ assistant’ posts.
The role of doctors in these assistant posts was to perform clinical
investigations and to ensure that the results were accessible to others
working within the trust. These posts were advertised within the trust and
also to the local refugee doctors’ group. Two refugee doctors were
appointed as doctors’ assistants in May 2004.
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Evaluation
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A 360° evaluation was undertaken of improvements in service following
the appointment of the doctors’ assistants. A postal survey of all
junior doctors on the three sites where the scheme was in place was undertaken
at the end of the first year of the project. Rates of haematological
investigations before the scheme and at 12 months were compared. A small
number of in-patients were asked for their views on the role of doctors’
assistant, and those involved in the scheme were asked to assess the impact of
the new posts.
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Outcomes
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Junior doctors
Junior doctors were surveyed at the end of the first year of the project.
Of 20 senior house officers, 15 completed the survey; 14 said that their
workload had been significantly reduced and commented that this had given them
more time to spend with patients in a therapeutic role. All those who
responded rated the doctors’ assistants (on a five-point scale) as
either ‘efficient’ or ‘extremely efficient’. Moreover,
14 of 15 respondents rated their liaison with other clinical staff as either
‘good’ or ‘extremely good’. Several also commented
that their reliability and specialised skills in performing investigations
made the experience less distressing for the patients. Others remarked that
they did not consider routine phlebotomy as a medical task and therefore it
was right that this was no longer required of them.
Investigations
One concern had been that by making it easier for doctors to request
investigations without having to perform them, there would be an inappropriate
rise in the number of investigations. Data provided by the local pathology
department, to which all samples are sent, were audited to determine the
number of requests for full blood count and urea and electrolyte tests over
two time periods. Over 3 months, before the appointment of doctors’
assistants, the pathology department performed 394 full blood counts and 55
urea and electrolyte tests. Over the same time period 6 months after the
introduction of the doctors’ assistants, there were 411 full blood
counts and 47 urea and electrolyte tests. This suggests that there was no
overall increase in investigations performed, although the clinical skill of
the two assistants might have been partly responsible for this; if there is a
request for a recent investigation to be repeated without an obvious clinical
indication, this is clarified with the doctor making the request before the
investigation is undertaken.
Pharmacy
Oxfordshire Mental Healthcare NHS Trust has never established a specific
service for patients requiring regular blood monitoring (e.g. those receiving
clozapine or lithium). In-patients frequently required urgent samples to be
taken before the pharmacy was able to dispense clozapine according to the
regulatory requirements. With the introduction of a partial shift system for
senior house officers, this situation was expected to worsen, resulting in
greater inconvenience to patients and cost to the trust. The doctors’
assistants, in conjunction with the pharmacy, have devised and implemented a
system for more efficient clozapine monitoring across the in-patient units,
which has substantially reduced the need for urgent blood tests and has
facilitated the recent introduction of a ‘near-patient testing’
system for clozapine.
Patients
Psychiatric in-patients are a particularly vulnerable group whose care is
significantly affected by staff changes and non-adherence to treatment. A
consecutive series of inpatients requiring phlebotomy were asked for their
opinions on the role of the doctors’ assistants. The clinical skill and
continuity offered by the doctors’ assistants were highly valued by
those patients requiring regular investigations, as was their dexterity with
the needle when compared with the psychiatric senior house officers. One
patient commented: ‘Before, someone different did it [took blood] every
time, you never knew if it would hurt or not. This way is better, you build
some trust.’
Refugee doctors
Both doctors’ assistants have access to training and resources that
help them work towards registration with the General Medical Council. They are
learning about the NHS and the way care is delivered, which will enable them
to contribute as fully accredited doctors at the earliest opportunity. The
library have been generous with access to study resources, including extending
membership to other refugee doctors not working within the trust, so that they
could continue to study as a group. All four study-group members passed the
recent Professional and Linguistic Assessment Board part 2 exams, and
attribute this in part to the ability to study together in a well-resourced
environment. In addition, both doctors’ assistants acknowledge that
their own sense of self-esteem has increased now that they are using some of
their considerable clinical skills to enhance patient care, rather than being
required to work in unskilled non-clinical posts.
Finally, both doctors’ assistants have been able to observe the
effectiveness of treatments for severe mental illness within the in-patient
settings, as well as the context in which psychiatry is practised. One author
(A.H.L.) is now aiming for a career in psychiatry.
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Conclusions
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The doctors’ assistants have made an impact at both personal and
institutional levels within the trust, beyond that anticipated when we devised
these posts. They bring with them a wealth of experience and are an important
positive image for refugees in this country.
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References
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BRITISH MEDICAL ASSOCIATION (2006) Refugee Doctors: Briefing
Note.
http://www.bma.org.uk/ap.nsf/Content/RefugeeDocsBriefingPaper#RefugeeDoctorsDatabaseBUTLER, C. & EVERSLEY, J. (2005) More Than You Think.
http://www.rose.nhs.uk/downloads/More_than_you_think.doc
DEPARTMENT OF HEALTH (2002) Guidance on
Working Patterns for Junior Doctors. London: Department of
Health.
ROYAL COLLEGE OF PSYCHIATRISTS (2003) Basic Specialist Training
Handbook. London: Royal College of Psychiatrists.
http://www.rcpsych.ac.uk/PDF/bst.pdf
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Introduction
Evaluation