a Division of Internal Medicine, University Hospital of Basel, University of Basel, Switzerland
b Shanghai University of Medicine and Health Sciences, Shanghai, China
c Centre for Psychosocial Medicine, Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
d Department of Geriatric Psychiatry, Psychiatric University Hospital Zurich, Switzerland
e Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, United Kingdom
f Institute of Biomedical Sciences Abel Salazar, University of Porto, Portugal
g Hospital de Magalhães Lemos, Porto, Portugal
Migration of medical professionals within Europe has been linked with unequal distribution of mental healthcare personnel, with Switzerland emerging as a major brain gain country. This study aimed to explore migration tendencies among psychiatric trainees in Switzerland to determine the push and pull factors of European transnational migration trends.
175 psychiatric trainees enrolled for postgraduate training in Switzerland took part in a self-administered questionnaire. Data were analysed descriptively and risk ratios and correlations were used to explore potential patterns in attitudes, experiences and tendencies to migration.
A majority of psychiatric trainees (82.9%, n = 145) were immigrants, mostly from Germany (40.6%, n = 71) and Austria (12.6%, n = 22). Top reasons for immigration to Switzerland were academic (16.8%), cultural (14.7%) and work related (13.5%). Major reasons for emigration from their home country were academic (16.3%), work related (16.3%) and financial (15.2%). Over 60% (n = 107) of the trainees had at least one earlier short-term mobility experience and a majority (n = 82) stated that it positively influenced their long-term emigration. Trainees with previous long-term migratory experience (n = 88) moved to Switzerland mainly after medical studies and before starting psychiatry training (n = 54). Only 9.7% (n = 15) of the immigrant trainees wanted to return to their home countries.
Academic reasons are major drivers of immigration to Switzerland, which is home to the highest proportion of immigrant psychiatric trainees in Europe. Swiss psychiatry training and working conditions might be a role model for European countries.
Keywords: psychiatry training, migration, brain drain, psychiatric trainees, mental health, public health
Migration of medical professionals to high-income countries is a global phenomenon and has been partially blamed for the healthcare workforce crisis [1, 2]. This “brain drain” of doctors was recognised in the 1960s amid mounting fears of unequal distribution of public health resources between the “donor” and “recipient” countries [3–5]. By 2000, an estimated 1.5 million medical professionals worldwide had emigrated from their home countries to settle in wealthier countries, impairing national health systems in many donor countries [6–8]. Global statistics on doctor-patient ratios reveal critical shortages of medical specialists in various countries and, given the rising prevalence of mental health disorders, psychiatry is among the most neglected specialisations [8–11]. The situation is exacerbated by fewer medical students opting to specialise in psychiatry, leading to underrepresentation of mental healthcare professionals .
Among the diverse push and pull factors of migration, financial advantages in recipient countries are understood to be the decisive reason for medical professionals [13–18]. In Europe, migration has been facilitated by laws on free movement of professionals across borders and accelerated since the expansion of the European Union (EU) in 2004 [12, 19–21]. Over these years, Switzerland has emerged as a major “brain gain” country for medical professionals. The proportion of foreign doctors in Zurich alone tripled between 2010 and 2019 [22, 23], leading to policies to restrict immigration from certain countries . Switzerland also employs the highest rate of psychiatrists per capita worldwide – almost double that of the second ranked country, Iceland . According to the Swiss Institute for Postgraduate and Continuing Medical Education, by 2020 there were 1352 psychiatric trainees in Switzerland, with 852 of them holding medical qualifications from EU countries .
Although the administrative, political and economic reasons for migration to Switzerland may be undeniable, studies are limited on what determines the choice of destination for psychiatric trainees for a specific country. Previously, attitudes to migration have been associated with the individual’s stage of medical training . Studying career mobility experiences in Switzerland and identifying the associated pull and push factors of migration for psychiatrists early in their career might help predict prospective models of migration among healthcare professionals and address concerns about brain drain/gain and uneven distribution of resources in Europe.
Since the Swiss public health system is widely praised for efficiency and studied as a model for healthcare reforms [15, 28–31], we aimed to investigate the motivations, trends and experiences of migration among psychiatric trainees in Switzerland.
In this article, we analysed the data on Switzerland from the European “Brain Drain” study  – a cross-sectional survey of psychiatric trainees carried out by the European Federation of Psychiatric Trainees (EFPT), the umbrella organisation of psychiatric trainee associations in Europe.
The EFPT national coordinator for Switzerland invited psychiatric trainees enrolled in postgraduate training at all major Swiss teaching institutions to take part in the Brain Drain study. The sole inclusion criterion was enrolment as a psychiatric trainee, that is, all medical doctors undergoing psychiatry residency under the nationally recognised programme. Medical students and psychiatrists were excluded. The survey could be completed either via an anonymous online platform (Survey Monkey) or as a hardcopy questionnaire (which was later added to the online database by the national coordinator).
The questionnaire was designed by the EFPT Research Working Group to fit the study population. An algorithmic layout allowed the respondents to complete it within 15 minutes, with the possibility of skipping the items that did not match their experience. The 61-item questionnaire covered sections on: (a) nationality and training specifications; (b) short-term mobility (i.e., more than 3 months but less than 1 year) and long-term migratory experiences (more than 1 year); (c) possibility of migration and features that make a job more attractive; and (d) sociodemographic variables. Further information about the questionnaire can be retrieved elsewhere [22, 32].
Consent and study approval
An introductory text containing information about the confidentiality of data, anonymity and the freedom to decline participation was included in the questionnaire. All participants provided informed consent before initiating the questionnaire, which was self-administered anonymously. The survey was conducted according to the principles of good scientific research practices and was approved by the Basel cantonal ethics committee (144/13).
Descriptive statistics were used – frequencies and percentages for attributive variables and the mean value with standard deviation for the numeric variables. Potential patterns in attitudes, experiences and tendencies to migration were explored using risk ratios and correlations. Data were analysed with the IBM SPSS Statistics (Version 20.0). Missing values were omitted and only valid percentages were reported.
A total of 175 psychiatric trainees (female 70.7%, male 29.3%) participated in the survey (response rate of targeted major hospitals 50%). A majority of participants were 30 years or older (71.4%, n = 125), in a relationship (64.5%, n = 113), without children (58.9%, n = 103) and earned more than €3000 per month (75.4%, n = 132). More than half (62.2%, n = 92) of the trainees were satisfied with their current salary, and 30.4% (n = 45) were very satisfied. No participants expressed dissatisfaction with salary.
A majority of trainees were aged between 30 and 40 years, were enrolled within the first to sixth year of the minimum of 6 years of training. Most were specialising in adult psychiatry (77.7%, n = 136), followed by child and adolescent psychiatry (17.7%, n = 31), old age psychiatry (4%, n = 7) and forensic psychiatry (0.6%, n = 1). The results are summarised in figure 1.
In Switzerland, 83% (n = 145) of the participant psychiatric trainees were immigrants with only 17% (n = 30) being Swiss nationals. Participating psychiatric trainees were primarily from Germany (40.6%, n = 71), followed by Austria (12.6%, n = 22), Greece (5.1%, n = 9), Italy (3.4%, n = 6), Serbia, France, Romania and Portugal (each 1.7%, n = 3). Figure 2 illustrates the percentage contribution of trainees from each European country.
Some trainees (6.8%, n = 12) reported commuting from neighbouring countries such as Germany, France, Italy, Austria or Lichtenstein to work in Switzerland. Those living within Switzerland were concentrated in downtown areas of Zurich (34.9%, n = 61), Basel (11.4%, n = 20), Geneva (7.5%, n = 13) and Bern (6.3%, n = 11). The other half was dispersed in suburban areas such as Schlieren, Uster and Wolfhausen. Most trainees (63%) migrated alone. Among those who migrated with company, 40% migrated with their family, 36.7% migrated only with their partners and 10% migrated with their parents.
Short- and long-term migratory experiences
In total, 61.1% (n = 107) of the trainees reported having previous short-term mobility experience (more than 3 months but less than 1 year). Most of the trainees moved once (n = 46), followed by those who moved twice (n = 23) and fewer (n = 15) moved three times, or between 4 and 10 times. The reasons for these short-mobility experiences abroad were academic (45.7%, n = 80), work (25.1%, n = 44) and volunteer work (8.6%, n = 15). The major destinations were the USA (9.1%, n = 16), Australia (4.6%, n = 8), Germany (7.4%, n = 13), Switzerland (6.9%, n = 12) and France (5.7%, n = 10). The experience was rated “very satisfying” or “satisfying” in most cases and influenced their attitude in favour of migration (90.1%, n = 82).
Overall 88 trainees (52.7%) had a long-term migratory experience (more than a year) abroad, mostly within Europe. Switzerland (25.1%, n = 44) was the most common destination country followed by Germany (6.9%, n = 12). Of these, more than half (58.6%, n = 51) migrated once, 27.6% (n = 24) migrated twice and 9.2% (n = 8) migrated thrice. Three trainees migrated four times and one trainee migrated five times for a long time period. These migratory experiences took place before medical school (13.1%, n = 23), during medical school (9.1%, n = 16), after graduation but before starting psychiatry training (30.9%, n = 54), during psychiatry training (12%, n = 21) and after psychiatry training (2.3%, n = 4). Figure 3 shows the migratory experiences of trainees.
Immigration to Switzerland
Among immigrant trainees, the top two reasons for immigrating to Switzerland were academic (16.8%) and cultural (14.7%), and for leaving their country of origin were academic (16.3%) and work related (16.3%) (table 1).
|Reasons for immigration||Cumulative frequency (N)||Relative frequency (%)||Reasons for emigration||Cumulative frequency (N)||Relative frequency (%)|
Psychiatric trainees found job opportunities in Switzerland to be attractive for several reasons (fig. 4). The main reason was a good work-life balance (68.4%, n = 106) followed by a pleasant environment and working conditions (67.5%, n = 102), supervision from senior staff (56.8%, n = 88) and professional opportunities (49.7%, n = 77). Of the 51 trainees who provided information on satisfaction with their migration experience, 54.9% were very satisfied, 35.3% satisfied and 3.9% were dissatisfied. Eighty-one trainees assessed their opportunities in comparison with locals: 60.5% considered themselves equal to Swiss citizens. The inequalities were either in the context of working, financial and social opportunities, whereas cultural, political, and personal opportunities were less prominent. Some trainees included a specific reason why they felt less privileged, mentioning the language and the difficulty to forge personal relationships with the native Swiss population.
About 55% of participants aimed to stay in Switzerland within the next 5 years of the survey. Fifteen percent were planning to work in a different country, 12% took practical steps towards migration. Only 9.7% participants were planning to go back home within the next 5 years.
This study presents the opinions and experiences of Swiss native and immigrant psychiatric trainees, providing an overview of the driving forces of professional migration for psychiatrists. The main reason for trainees to emigrate from their home country, as well as for choosing Switzerland, was academic opportunities. In the overall European findings of this study, the top reasons given by immigrant psychiatric trainees for leaving their countries were financial (e.g., salaries), personal (e.g., partner, children, family) and academic (e.g., training or educational opportunities). Personal (56.3%) reasons were the main factor for staying in their home countries and only 13% of the European trainees had emigrated because of academic reasons . Although high income in top host countries (such as Switzerland, Sweden and UK) has been understood as a major driver of immigration , economic reasons alone may not justify all migration tendencies.
Swiss psychiatry programme
Academic reasons as the driving force of migration to Switzerland might be due to the perceived high standards of Swiss psychiatry training among the European psychiatry community. The Swiss programme comprises 6 years, which is 2 years more than the minimum requirement for the EU’s automatic recognition of credentials . The first 3 years are intended to develop basic competencies, but the training includes a minimum of 2 years (each) of experience in an outpatient and an inpatient unit with a special grading of the psychiatric hospital in terms of acute treatment and 1 year in selected somatic medicine disciplines, according to the regulations of the Swiss Medical Association (FMH) and Swiss Institute for Medical Education (SIWF). Despite these limitations, the Swiss programme still allows for more freedom than other countries such as Germany, where, for instance, 1 year in neurology is mandatory . To complete the minimum of 6 training years in Switzerland, there are several options, such as 1 year in child and adolescent psychiatry or up to 1 year of clinical research that can also be accredited. The curriculum includes clinical practice, basic skills and a minimum of 600 credits (corresponding to 45–60 minutes each) of theoretical courses, at least 330 credits of supervision with 150 hours supervision in integrated psychiatric-psychotherapeutic treatments, 150 hours of core psychotherapy supervision and 30 hours of continuing education supervision, supervised practice of psychotherapy (minimum 300 sessions) and psychotherapeutic self-awareness experience (80 hours minimum) . For comparison, this is approximately half of the self-experience that is required in Bavaria, Germany where 150 hours and 35 double-hours of group-guided self-experiences such as Balint are required . Since extensive training in psychotherapy is part of the curriculum, a specialist title in “psychiatry and psychotherapy” is awarded upon completion of training . Further unique characteristics of the Swiss training system are the mandatory e-logbook of training activities, and workplace-based assessments (mini clinical examinations) 4 times per year .
A vast majority of the participants were non-Swiss, confirming that Switzerland is a major brain gain country for medical professionals [22–24]. Most migrant trainees were from Germany and Austria, which may be explained by the proximity of the countries as well as a common spoken language, German. Some participants were working in Switzerland but living in neighbouring countries. The proximity of Germany, Austria, Italy and France to Switzerland and freedom of movement allows professionals to cross the borders for work either every day or to stay in Switzerland during weekdays and return home for the weekend. Although Switzerland is among the most expensive countries in Europe based on purchasing power parity, taxes are lower in Switzerland than in its neighbouring countries and the net salary after tax in home countries for these commuting professionals might be lower when compared to their Swiss counterparts [36–38]. This balances out the supposed lower costs of living across the border, suggesting that personal and family reasons, in addition to perceived economic benefits, could be the primary motivations for commuting to work in Switzerland.
Most participants also had prior international mobility experience. The majority migrated alone or with their partners or family and were very satisfied with moving to Switzerland. This suggests that Switzerland is a welcoming country for foreign psychiatric trainees and encourages professional mobility. About 40% of the participants expressed apprehensions about discrimination or feelings that they did not have the same opportunities as Swiss natives. This may have lasting implications, especially considering the continuous political debate about limiting immigration into Switzerland. Nevertheless, about 90% of the participants did not plan to go back to their home countries within the following 5 years.
As many European countries struggle to cope with the lack of physicians, particularly psychiatrists, identifying reasons for migration is the first step towards alleviating mental healthcare inequities. Mental health is an underfunded medical specialty in many European countries and Switzerland is a favourite destination for medical professionals, making it an ideal case for studying migration trends in Europe. Although we investigated unexplored aspects of brain gain and drain in a specific population and area, giving new insights and providing a base for further research on migration to Switzerland, it can be argued that the convenience sampling method may not allow generalisation of results.
Psychiatric trainees in Switzerland are of particular interest since over 80% of them were found to be immigrants, as compared with the European average of 13.3% immigrant trainees [22, 39]. These numbers are staggering considering that the country had restricted the influx of EU doctors for over 10 years, with stricter immigration policies for medical students and doctors between 2000 and 2012. These policies were withdrawn after widespread criticism [39, 40].
Policymakers, hospitals and key stakeholders can benefit from these findings in order to establish an appealing teaching and working environment, since these aspects have been mentioned as primarily important to the trainees, both Swiss and immigrants. Switzerland already enjoys advantages over other European countries, such as the stable economic situation, safety and culture. However, trainees still considered leaving the country if they perceived discriminatory attitudes in the work setting or if they did not obtain adequate teaching or career development opportunities.
Workforce migration has immense sociocultural, financial, educational and infrastructural impacts on public health systems. The predominant reason for migration of psychiatric trainees to Switzerland was not economic but the academic interest in studying in Switzerland. Immigration of trainee psychiatrists to Switzerland could be termed “atypical” since trainees foremost considered educational and cultural reasons. This may be perceived as “mobility of choice” versus migration driven by financial constraints, since these flows are not strictly unilateral and are shaped by diverse, individual motives.
We would like to thank the European Federation of Psychiatric Trainees (EFPT) for supporting this project. FB gratefully acknowledges to be supported by the Olympia-Morata fellowship programme from the Medical Faculty of the Heidelberg University. This publication is dedicated to the mother of one of our co-authors, who lost her life to COVID-19 in these unfortunate times when so many people have been affected by the coronavirus pandemic.
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
No potential conflict of interest relevant to this article was reported.
Dr Franziska Baessler, MME, MD, Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 410, DE-69120 Heidelberg, franziska.baessler[at]med.uni-heidelberg.de
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