Should I migrate or should I remain? : professional satisfaction and career decisions of doctors who have undertaken specialist training in Fiji
Oman, Kimberly (2007) Should I migrate or should I remain? : professional satisfaction and career decisions of doctors who have undertaken specialist training in Fiji. PhD thesis, James Cook University.
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Introduction: Fiji is a Pacific Island nation that prior to the mid-1990s relied mostly on expatriates for its specialist workforce, and few Fiji doctors who obtained overseas specialist qualifications returned home to work. To address this problem, regional specialist training for the Pacific was established at the Fiji School of Medicine (FSMed) in 1998, and it was assumed that local training along with a non-exportable specialist qualification, would lead to improved retention. After several years, it became apparent that many doctors who started training resigned from the public service, with most migrating. While this accelerated around the time of the coup of 2000, it has continued since then. This coincided with a worldwide increase in the migration of health workers. The purpose of this study was to determine why doctors who undertook specialist training at FSMed chose to migrate or stay, with a focus on the issues of professional satisfaction and dissatisfaction. It was hoped that a deeper understanding of the situations of these doctors would suggest interventions that could improve their retention and overall satisfaction.
Methodology: The research was carried out as a mixed method, though predominantly qualitative study. The study focused on the “case” of the establishment of postgraduate specialist training in Fiji. Altogether, 47 Fiji doctors were interviewed, including 36 of 66 doctors who attained an FSMed Diploma or higher. Doctors in the public sectors, in private practice, as well as migrants were included. Semistructured exploratory interviews were carried out between 2004 and 2006 and were taped, transcribed, coded and analysed using a constant comparative method, with the identification of emerging themes from the interview data.
Results: The results are presented over 3 chapters exploring professional satisfaction, migration, and career pathways. A model of professional satisfaction was developed that included three major elements of professional growth, service and recognition. Professional dissatisfaction could be conceptualised as the absence of or the blocking of the elements of professional satisfaction. Dissatisfaction was particularly directed at the Ministry of Health, and a failure to reliably provide basic medications and supplies, as well as problems with career advancement, were frequently mentioned. Of the 66 doctors, 20 had migrated permanently and the 7 who were interviewed cited family security (mainly related to the coup of 2000) or spousal career or family issues as being central to their decision-making. Fijian but not Indo-Fijian doctors also cited the contributing factors of limited career advancement opportunities, low salaries and poor working conditions. Nine of these doctors entered private practice in Fiji. The four who were interviewed generally cited desires to spend more time with their families and gain control of their working lives, though frustrations with career advancement were also mentioned. No doctor who resigned cited higher salaries or improved training opportunities as the predominant factors in their decision-making. The doctors who remained in the public sectors usually mentioned a service ethic, often grounded in religious belief, as well as close attachments to family, extended family and culture. Overall, while many spoke positively about postgraduate training, most cited significant stress from managing their academic loads on top of very busy public hospital postings. Some trainees, mainly in the procedural disciplines, complained about inadequate clinical supervision. Of the 42 doctors who left training with a Diploma as their highest qualification, only 13 have remained in the public sectors. Family issues predominated as reasons for leaving training, especially time pressures for female doctors, and difficulties in supporting families on low salaries for male doctors, though some resigned in order to migrate. Of the Masters graduates, 18 of 21 (plus three current students) are still in the public sectors, some of whom still remain at the lowest career grades. Overall, doctors complained of unpredictable career advancement, with a Masters or Diploma seeming to have little impact, as well as bottlenecks from limited numbers of senior postings.
Discussion: A constructivist approach to these interviews suggested that overall these doctors saw public hospital work as an expected “norm” that offered many satisfying career aspects, while other career options were to some extent compromises. One of the few “justifiable” reasons for leaving the public system seemed to be family welfare. The blocking of professional development and advancement was cited by doctors who considered resigning, but by fewer who actually resigned. This suggested a centrality of the professional values of service, patient welfare and treating patients regardless of their ability to pay, and these values overlapped considerably with the elements of professional satisfaction. The findings from this study fit with and expand on previous research from Fiji, and also fit well with the world literature, where there was agreement on the frustrating elements of lack of infrastructure support (especially drugs and supplies), difficult working conditions, staff shortages and problems with career advancement. Salaries in Fiji are modest though arguably “liveable”, and were less of an issue than elsewhere. This study expanded somewhat on satisfying aspects of medical practice, including camaraderie, mentoring, being of service and making a difference. While health worker motivation is widely mentioned in the literature, there was at best an uncomfortable fit with existing theories, possibly related to much of the literature being focused on worker alignment with organisations, while health workers are more likely to be aligned to their professions. This study was limited by having studied only specialist doctors from a small country, and this may limit applicability elsewhere. Overall, the study suggested that retention in Fiji could be increased through improved provision of basic medications and supplies as well as through the development of transparent career pathways, through tying advancement to postgraduate training, and through trying to make workloads for trainees more tolerable in order to increase Masters completions. While in other countries the provision of a liveable wage may be more important, these interventions may also prove to be effective elsewhere in the world.