Future psychiatrists are considering leaving Australia, saying an exam scrapped in other English-speaking countries is ruining their chances of practising.
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Australia's mental health system is buckling under the pressure of COVID-19, with an acute psychiatrist shortage exacerbated by Australians reaching out for help in record numbers.
The country was previously warned it faced a shortfall of 450 psychiatrists by 2025, particularly in regional areas. But nearly a decade on, its only accreditation body is still struggling to bring recruits into the workforce.
One Royal Australian and New Zealand College of Psychiatrists board member admits "we have a problem", and reform is needed to avoid Australia bleeding would-be psychiatrists at a critical time.
The final, often impossible hurdle is an exam found not to reflect the "real-world" skills needed to work as a psychiatrist. A number of trainees are failing the test multiple times, despite being fully accredited in other English-speaking countries.
They have told The Canberra Times they may have no choice but to leave Australia, saying ongoing uncertainty has put their lives on hold, damaged their finances, and threatened their relationships.
'We're stuck'
The RANZCP has complained COVID-19 is hampering its ability to pass students. Exam delays, cancellations, and technical glitches in that period have led 97 per cent of students to report a "very significant" or "significant" impact on their emotional wellbeing.
But many say the problems predate the pandemic.
Just a few years ago, roughly 80 per cent of trainees were falling at the final hurdle: an essay exam with question marks over its relevance. That number has fallen after outcry, though most applicants still fail.
Australia is one of few countries still using the test; Canada scrapped it in 1989, finding it was of "limited reliability", before the UK followed suit in 2007.
And a 2020 report from the Australian Council for Educational Research (ACER) raised concerns over its relevance.
"It is unclear how the skills being assessed under the examination conditions reflect the real-world practice of being a psychiatrist," it read.
Father-of-two Mpho Radebe has worked in multiple towns across regional NSW, but says the exam is preventing many trainees like him from serving rural communities.
After he passed the remainder of the course at the first attempt, his wife left her job to accommodate his training needs, believing their income would soon increase significantly.
But Mpho has now failed the essay test six times, each attempt costing around $1800. He says the continual uncertainty over his future, along with a loss of income, has placed huge strain on his home life.
"My family has been put in jeopardy, I nearly lost my marriage," he says.
"My wife was really upset when I had to leave Bathurst, where basically I had been working every day providing a stellar service. It was the most painful thing.
"If we don't pass this exam, then we don't become psychiatrists and our lives are not as flexible. So we're stuck."
Each failure was met with feedback of no use from the College, he says.
"Even our bosses have said: some of this is just not relevant to what our colleagues do. Why are we putting them through this?" he says.
After the ACER report found the test disproportionately impacted students from non-English speaking backgrounds, Botswana-born Mpho wrote to the College arguing it was discriminatory.
He believes the letter he wrote, which received only an acknowledgment of receipt in response, is behind his continual rejection.
"I was making allegations about discrimination which bordered on racism ... They passed all the other guys who were in that group, and I was left," he said.
"I'm not sure if they bear grudges. If so, it would be mafia-like, and very sad for the profession."
'We have a problem'
While the pass rate has increased since the College split the exam into two, RANZCP board member Nick O'Connor accepts "we have a problem".
Dr O'Connor says "we'd be further along" were it not for COVID-19, but admits there is a need for a "better and deeper engagement" with trainees over ways to improve the system.
"We're looking to see if we can move away from high-stakes, single event, time-pressured examinations, to an exam that is more related to the real world," he says.
Trainees from non-English-speaking backgrounds are particularly likely to work in regional and rural communities, and Dr O'Connor insists the College is doing a "lot of work" to boost language skills.
But with many trainees failing the essay exam despite being accredited in other English-speaking countries, he is concerned Australia is bleeding talent.
"I think we have a really important asset in these people that we need to be nurturing and supporting," he says.
For those who have failed the test, Dr O'Connor accepts the College had fallen short in providing feedback.
"I think we can improve on it ... We have to really listen," he says.
"We [need to give] feedback to our candidates about their performance in a way that is constructive, and facilitates them addressing the gaps that we might have identified."
'Pick up the pieces'
One trainee, who wished to remain anonymous over concerns for her career, is leaving for a job in Dubai.
She is fully accredited in the UK and the Middle East, where she practised for years, and has also received job offers in Canada. But having attempted to pass the test four times since 2016, she has given up hopes of a career in Australia.
"I kept trying and pushing, and pushing, and pushing because I was looking to settle here in Australia, have a life here, buy a house here," she said.
"They never gave me the opportunity. They affected my life not only emotionally and financially, but my whole future has been ruined after a few years of trying so hard."
She says she passed both her degrees at the first attempt, but has been rejected four times at the final hurdle in Australia.
"Every time it took me a lot of energy to pick up the pieces and tell myself: it's all right, things will be fine, go for another attempt," she says.
Students are in limbo, she says, unable to commit to their current work due to the intense requirements for study. A number of her colleagues were taking compassionate and stress leave, as they grappled with repeated rejection and uncertainty.
"The college is disregarding the impact they have over our lives, and [our ability to] make future decisions. It's overwhelming," she says.
She wrote to the RANZCP to outline the financial and mental toll the process had taken.
"Mentioning those facts and writing them down provoked heaps of emotions. I was in tears for a week just to finish that letter," she says.
The Canberra Times has seen the RANZCP's response, which appeared to be a generic email.
'This is all you get'
Another trainee, who also wished to remain anonymous, was booted from the course after an 11-month process, following his fourth attempt.
He is fully accredited in the UK, has five years' experience in Ireland, and can return to work in Europe. But with his wife and children settled in Australia, where they have been since 2005, he wants "one more shot" at qualifying here.
"I just wanted to make a difference with rural and regional communities. [But] I'm already qualified, so I may have to consider leaving Australia," he says.
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"I wanted to know my areas of strength, areas of weakness ... [But] if you ask for more, they say: this is all you get," he says.
Believing the psychiatrist shortage brought on by COVID-19 might have prompted a rethink, he wrote to the College asking them to reconsider.
He was given the option of moving to New Zealand, where the rules are less rigid.
He says more adaptability and compassion from the College would go some way to addressing the regional mental health crisis.
"We will be saving more lives. We will be serving and doing justice to the most disadvantaged and vulnerable suffering," he says.
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