Abstract
Recruitment into psychiatry is an issue that has exercised our profession over many years with multiple publications in educational and professional journals addressing the professions concerns internationally [1–6].
In this journal Malhi et al [7] studied the personality, preferences and perceptions of medical students and whether these correlated with consideration of psychiatry as a career. Like many others, they found negative perceptions of psychiatry as being ‘unscientific’ and “…somehow different to mainstream medicine in terms of training and outcomes”. Interestingly they also noted that there was little different with respect to personality in those students choosing psychiatry in comparison to their peers, apart, that is, from an increased tendency to be “open” i.e. “intellectually curious, emotionally aware and independent in judgement”.
The Recruitment Crisis
The Royal College of Psychiatrists' annual census has, over many years, demonstrated vacancies in UK consultant psychiatrist posts as being stable in the 10–15% range [8]. At the same time the interest in psychiatry amongst UK medical students has remained static at around 4–5% which is insufficient to meet demand. This is despite changes in the demographics of recruitment to undergraduate medical courses, with more female students, and changes in the ways in which the speciality is taught. Brockington and Mumford [9] pointed out that standard selection criteria for medical schools emphasises competency in physical and biological sciences over social sciences and the humanities. Indeed it has been the case for some time that passes in physics and chemistry are rated more highly that biology itself in many medical schools. It may be the case that our courses actually reinforce this as illustrated by Silvermann et al [10] in the US showed that when patients with chest or abdominal pain were assessed by Boston medical students they were unlikely to consider possible psychosocial factors in the patients' presentation.
Prem Shah et al [11] in a study looking at Scottish doctors in the first two years after qualification identified three broad areas that they felt impacted positively on choice of psychiatry as a career. The first was early medical school experience; the second the influence of seniors and the third aspects related to the working environment. Many authors have considered the first of these areas and Shah et al's findings are not unique in this regard. In a study looking at the views of Scottish consultant psychiatrists about recruitment into psychiatry Brown et al [12] identified five main areas which this group felt had influenced their career choice. Fifth amongst these was undergraduate medical experience (the others were, in descending order; interest in, and concern for, the mentally ill; being more interested in people than diseases; a greater interest in social aspects of medicine; an ability to tolerate ambiguity) which has been highlighted by a number of authors as affecting interest in our speciality. Baxter et al [13], McParland et al [14] and C Holm-Peterson [15] all showed that attitudes and interest in psychiatry both improved with exposure to teaching in the discipline. Unfortunately both Baxter et al and Maidment et al [16] in a follow up of the McParland cohort showed that this interest declined as students continued through their training.
More worryingly perhaps is that the work by Shah et al that showed that in newly qualified Scottish doctors (in the first two months of their first job) only 1.9% placed psychiatry at the top of their list of potential career choices rising to 4.8% late in their second year, by which time some had worked in psychiatry. In looking at those considering psychiatry in their second year, there was a significant correlation with having held a post in psychiatry and this was particularly evident in comparing change in attitudes between years one and two. Of further interest was that as junior doctors progressed through their first two years of training, the influence of their undergraduate experience diminished in importance. Whilst seeing that exposure to working in our profession has a positive impact is not, perhaps, surprising it is important to use this to counter the potential nihilism that many feel in considering the recruitment crisis by recognising that there are things we can do to change attitudes to pursuing psychiatry as a career.
Understanding Why Our Speciality Is Unpopular
Enabling us to address the issue of recruitment requires an understanding of not just what attract students and doctors to psychiatry but also what turns them off the speciality. A number of authors from various countries have looked closely at what students' views of psychiatry are [2, 17–18] and why those who do look favourably on the speciality as students do not choose to follow it as a career [19]. Feifel et al [2] in a survey of new entrants to US medical schools found that whilst many valued elements of clinical practice that are central to psychiatry, aligning closely with those detailed by Brown et al above, they viewed psychiatry as the least attractive of the various medical specialities asked about. Most worryingly is that 25% of these students, who were all only two weeks into their training, had already ruled psychiatry out as a possible career option. Malhi et al [3] replicated this study in Australia with broadly similar results. Again psychiatry was seen as an unattractive career choice but at the same time many saw it as “interesting and intellectually challenging”. In a study looking at Australian undergraduates late in their course Wigney and Parker [20] found that factors that caused students to reject psychiatry as a career choice included a perceived lack of scientific underpinning and the attitudes of our peers in other branches of medicine. Most authors who have looked at what influences students and trainees [2, 11, 12, 19] have identified the issue of stigmatic views of our fellow doctors with a belief that there was a lack of science to back up approaches and treatments also impacting [3, 10, 11, 19]. Somewhat ironically perhaps at a time when commentators outside the medical profession continue to attack the perceived reliance on biological models.
A Call To Arms
In understanding some of the factors affecting the choices of students and recently qualified doctors where should we go if we want to effect any change in recruitment? It's clear that students come to medicine with a set of values shaped by their own personality and life experiences. More than one author [1, 3] have suggested targeting those students who are most likely to be well disposed to a career in psychiatry but it is clear that to target this group alone we cannot expect to fill the gaps that exist. There is good evidence that by delivering high quality educational experiences in psychiatry we can encourage students to consider it as a career. Equally by ensuring that training jobs are provided in increasing numbers in the immediate post-qualification years we have a chance to change minds and reinforce previously positive views. Whilst Shah et al have indicated that the value of undergraduate teaching became neutral by the second year post qualification, a poor experience as an undergraduate will lead young doctors to be less receptive to our speciality. The shape of our training needs also to address perceptions of others with an increased emphasis on the scientific evidence base behind modern psychiatry. A word of warning though. To do this at the expense of the open and holistic approach that encourages many of our current recruits and is cited as driving the decisions of our current consultants, risks alienating our current recruitment base. Finally we need to address some of the other negative influences and here we face a greater challenge. Many of our colleagues hold very negative views about psychiatry, psychiatric patients and psychiatrists. We currently tend to work in silos separate from our more visible GP, physician and surgical peers. Instead of blaming others for our recruitment crisis it falls to us to engage students and trainees. By delivering care to patients and educating our colleagues, in visible general settings, to a standard that engages and impresses we have the chance to lead and inspire by example.