Becoming a psychiatrist in Europe: the title is recognized across the European Union, but what are the differences in training, salary and working hours?

The professional qualification as a psychiatrist is automatically recognized across Europe if a national training program fulfils the minimum requirement of four years of training duration (1,2). This is applicable to all 28 European Union (EU) member states, as well as to other countries of the European Economic Area, such as Norway and Switzerland (2). However, what is equivalent on paper may be not in practice: patients and hospital staff increasingly encounter doctors with different educational backgrounds due to the open European labour market and the mobility of trainees and psychiatrists.

In 2014/2015, the European Federation of Psychiatric Trainees surveyed training in psychiatry by a questionnaire directed at representatives of national psychiatric trainee associations. Except Cyprus, Czech Republic, Latvia, Luxembourg and Spain, all EU countries were covered.

A medical practitioner who undergoes postgraduate training in psychiatry and qualifies as a specialist is called a psychiatrist. Only in the German speaking countries, i.e. Austria, Germany, Switzerland and Liechtenstein, the specialist holds the title of “psychiatrist and psychotherapist” (2), even though training in psychotherapy is a mandatory part of psychiatric training in most European countries (3).

Although skills in psychotherapy are widely considered essential for psychiatrists, the number of patients to whom trainees are required to deliver psychotherapy varies and can be as little as zero, as in Estonia (4). In some countries, e.g. the Netherlands, child and adolescent psychiatry is a subspecialty of “adult” psychiatry. In other countries (25 out of 31) it is a separate specialty with up to 600 trainees (as reported from UK). However, only in Belgium the title specifies that a psychiatrist is specialized in adults (“psychiatrie de l’adulte”) (2). A title such as “general psychiatrist” (awarded in the UK) could help differentiate subspecialties and underline the balance of technical and non-technical elements of care (5).

In order to match the EU minimum requirement, training duration needs to be four years or longer. The maximum required training durations are seven years in Ireland and six years in Austria, Finland, Switzerland and the UK. Training is not nationally standardized in four out of 31 countries (Belgium, Finland, France and Greece), underlining the challenge of establishing a single, unified European exam. In some countries it is required to rotate in a university hospital (six months in France) or a psychiatry ward in a general hospital (six months in Greece), or to spend twelve months in another hospital (Switzerland), pushing trainees to switch workplace. Outpatient care is strongly enforced in Finland, where half of the training has to take place in outpatient care. Overall, national curricula are still mainly defined by total duration and duration of rotations in (sub)specialties, despite the benefits of competency-based training (which may also facilitate a pan-European exam).

Appropriate working conditions, including salary and working hours, are essential for high-quality clinical training. Trainees in EU countries work 35 (Bulgaria) to 65 hours (Malta, including on-call hours) per week. Non-EU countries are characterized by less working hours: 35 hours per week in Belarus, Russia, Serbia and Ukraine. Income varies from 90€ per month in Ukraine to >4,000€ in Switzerland, i.e. in some countries trainees earn 44 times more than in others. The top-five countries in terms of average monthly salaries, mostly including on-call hours, after tax deduction are Switzerland, Sweden and the UK (≥4,000€), Norway (3,400€) and Germany (2,900€), while the lowest monthly salaries are paid in Ukraine (90€), Bulgaria (140€), Belarus (150€), Russia (150-500€) and Romania (400€). In Portugal (1,200€) it is common for trainees to spend a period abroad, during which they continue to be paid by their institution. Trainees in Belgium are paid (1,900-2,400€ per month) by their supervisors, which may cause conflicts of interest. Notably, not all aspects of training (especially parts of the psychotherapy curricula) are free of charge for trainees (4), further reducing their spendable income.

In most countries (17 out of 31), too few medical practitioners choose psychiatry as their specialty, yet initiatives to increase recruitment are lacking. As a consequence, in 16 countries, not all vacant positions are being filled, and only in very few countries (e.g., Greece) demand for training positions exceeds openings.

Thus, the characteristics of psychiatric training vary widely across Europe, despite an open labour market where specialists frequently work in foreign countries. The fact that the qualification of psychiatrists is equivalent throughout Europe should stimulate international cooperation when re-designing training curricula. Guidance and support by international organizations such as the European Federation of Psychiatric Trainees (6), the European Psychiatric Association (7), the European Union of Medical Specialists (8), the World Health Organization and the WPA are crucial in order to facilitate harmonization of curricula. To improve local implementation, an international system of training programme inspections should be established.