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Recruiting psychiatrists – a Sisyphean task?

  • Nick Brown (a1), Christopher A. Vassilas (a2) and Clare Oakley (a3)
Summary

In 2009, the Royal College of Psychiatrists piloted a system for national recruitment to the first year of training (CT1) in England. This paper reviews the changes in recruitment of UK medical graduates to psychiatry over the past 20 years, both within the West Midlands and nationally. Fewer UK graduates are entering psychiatric training in the West Midlands despite the introduction of pre-registration training in psychiatry and the expansion of medical schools in the region; this picture is reflected nationally. Reasons for the continuing problems in recruitment are discussed and suggestions made for improving the attractiveness of psychiatry as a medical specialty. the latter include: engaging more closely with medical students, continuing to lobby politically with regard to overseas recruitment and presenting a unified vision of the profession.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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1 Oxtoby, K. Psychiatry in crisis. BMJ 2008; Classified suppl: 27 August.
2 Brockington, IF, Mumford, DB. Recruitment into psychiatry. Br J Psychiatry 2002; 180: 307–12.
3 Khan, A, Oyebode, F. Evaluation of a psychiatric training scheme. Psychiatr Bull 1993; 17: 158–9.
4 Royal College of Psychiatrists. Tackling psychiatry's recruitment crisis head on. RCPsych News 2008; November (http://www.rcpsych.ac.uk/member/rcpsychnews/november2008.aspx).
5 Tyrer, SP, Leung, WC, Smalls, J, Katona, C. The relationship between medical school of training, age, gender and success in the MRCPsych examinations. Psychiatr Bull 2002; 26: 257–63.
6 Crisp, A, Gelder, M, Goddard, E, Meltzer, H. Stigmatisation of people with mental illnesses: a follow up study within the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry 2005; 4: 106–13.
7 Luty, J, Fekadu, D, O'Garga, C, Gallagher, J, Umoh, O, Mahadevappa, H. Professional status of psychiatrists: good but not great. Priory, 2007 (http://priory.com/psych/status.htm).
8 Lambert, TW, Turner, G, Fazel, S, Goldacre, MJ. Reasons why some UK medical graduates who initially choose psychiatry do not pursue it as a long-term career. Psychol Med 2005; 36: 679–84.
9 Eagles, JM, Wilson, S, Murdoch, JM, Brown, T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull 2007; 31: 70–2.
10 Darzi, L. High Quality Care for All: NHS Next Stage Review Final Report. Department of Health, 2008.
11 Vize, C, Humphries, S, Brandling, J, Mistral, W. New Ways of Working: time to get off the fence. Psychiatr Bull 2008; 32: 44–5.
12 Craddock, N, Antebi, D, Attenburrow, MJ, Bailey, A, Carson, A, Cowen, P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 69.
13 Scott, J. What puts medical students off psychiatry? Psychiatr Bull 1986; 10: 98100.
14 Creed, F, Goldberg, D. Students' attitudes toward psychiatry. Med Educ 1987; 21: 227–34.
15 Sierles, FS, Taylor, MA. Decline of U.S. medical student career choice of psychiatry and what to do about it. Am J Psychiatry 1995; 152: 1416–26.
16 McParland, M, Noble, LM, Livingston, G, McManus, C. The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career. Med Educ 2003; 37: 447–54.
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Recruiting psychiatrists – a Sisyphean task?

  • Nick Brown (a1), Christopher A. Vassilas (a2) and Clare Oakley (a3)
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eLetters

Flying the Flag for Psychiatry

Asif M Bachlani, Str 6 General Adult Psychiatry
23 August 2010

Dear Editor

As a trainee coming up to CCT date I as many trainees are aware of the lack of future psychiatrics with figures quoted of 10- 15% (1) shortage. Furthermore there is the realisation that only a minority of UKgraduates (2) choose psychiatry as a speciality. The Royal College has recognised the vast problem and helped develop psychiatry societies withinuniversities and improve undergraduate teaching. There is a fair understanding of the reasons for the poor uptake of psychiatry in the era post MMC all of which is depressing to read.

It feels that Sisyphus curse is not difficult enough it is being hindered. May I suggest a different view where we as psychiatrists (trainees or consultants) do more to sell the virtues of a career in psychiatry. We need to aware of what is said of the disadvantages of psychiatry as a career – chronic illnesses that are not cured, that psychiatry is not scientific enough (3) or that we all go mad in the end; but not enough is said about the advantages. I think we should acknowledge these claims upfront and challenge them as well as sell psychiatry as a career. This is especially important as there is evidencethat psychiatry is often demonised as a career by other specialties (1).

We should also consider factors that have influence career choices – income and prestige of specialty within medicine (4), influence of positive role models and undergraduate exposure (5). Finally we should consider what specialities we may be competing against iwhich I believe isGeneral Practice and Paediatrics.

So lets be upfront about the advantages of psychiatry:•Opportunity to develop long-term patient relationships (like GP) •We treat patients as individuals and holistically. •Opportunities for private practice which tackles income (Medicine/surgery).•Opportunities for flexible training and consultant posts (GP/Paediatrics).

Onto tackling some of the criticisms; there are also a lot of chronicphysical health conditions (such as diabetes, asthma) that are not cured. That there is science behind mental health illnesses and treatments, and as with any career there are certain personality traits that are drawn to different specialties.

Another major area which I feel we can do more is in our clinical practice where we ensure medical students have a positive undergraduate experience:

1. Patient contact – Sufficient opportunities to clerk patients, if observing assessments make this an active process where they are taking part or all of the history, discuss MSE or management plans, or observe your interview style.

2. Be dynamic and approachable as a clinician so students feel comfortable asking questions and engaging in debates surrounding patient issues.

There has and will be concerns about time involved taken to engage with these activities. The GMC is clear about our responsibilities for teaching, but lets be pragmatic we need to encourage students to become psychiatrists otherwise we will be up the creek with no paddle.

Come on lets’ give Sisyphus a helping hand and give him a wheelbarrowat least!

References1. Brown T, Addie K and Eagles J. Recruitment into psychiatry: views of consultants in Scotland. Psychiatric Bulletin (2007), 31: 411- 413.

2. Brown N., Vassilas C. A. & Oakley C. Recruiting Psychiatrists – a Sisyphean task? Psychiatr Bull 2009; 33: 390-392.

3. Rajagopal, S Rehill K.S and Goddrey G Psychiatry as a career choice compared with other specialties: a survey of medical students Psychiatric Bulletin (2004), 28: 444- 446

4. Dale A. Newton, MD, Martha S. Grayson, MD, Theodore W. Whitley, PhD What Predicts Medical Student Career Choice? JOURNAL OF GENERAL INTERNAL MEDICINE, 1998, 13; 200-2003

5. Goldacre,M. J.,Turner, G. & Lambert,T.W. Variation by medical school in career choices of UK graduates of1999 and 2000. Medical Education, 2004, 38, 249-258.
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Recruiting psychiatrists - Where does the responsibility lie?

Vishaal Goel, Clinical Teaching Fellow/SpR in Psychiatry
20 December 2009

Dear Editor,

In the Dean’s May 2009 newsletter (1), Professor Rob Howard describedrecruitment into psychiatry as being at crisis point. Although much has been written (2,3) exploring the reasons behind this complex issue, one factor remains elusive; the issue of consultant motivation to teach.

Eagles et al (3) rightly mention that undergraduate experiences of psychiatry are fundamental in determining later career choices, but the question of where the responsibility for delivering positive and paradigm shifting teaching lies remains unanswered. Whilst it is true that any professional coming into contact with medical students must accept responsibility for projecting a positive image of psychiatry, it is my opinion that this ultimately lies with consultants.

Inspirational role models are of vital importance in creating the psychiatrists of tomorrow and there is a body of evidence supporting the importance of good role models in recruitment into medical specialities. Eager-to-teach consultants explaining the subtleties of psychiatric interview and using listening as a diagnostic tool fascinated me as a medical student and, moreover, being shown that psychiatry, like no other speciality, could be so contentious and stimulate such debate, won me over. My opinion was always valued and this, from consultants, who to medical students are mythological creatures, was nothing short of phenomenal. In fact, McParland et al (4) showed that students were more likely to choose psychiatry as a career if they received positive encouragement from consultants.

My own anecdotal evidence suggests that many consultants feel that teaching is less important than delivering effective patient care and manybelieve, because of the very realistic pressures of acute psychiatry, thatthey simply do not have sufficient time to teach. This has a direct impacton the students I encounter on a daily basis who feel uninspired, deflatedand irritated following their psychiatric attachments and, unsurprisingly,lack any motivation to consider psychiatry as a realistic career choice.

In its guidance on Good Medical Practice (5), the General Medical Council sets out the principles and values upon which good practice is founded. Paragraph 15 of the ‘Teaching and training, appraising and assessing’ section clearly states that:

‘Teaching, training, appraising and assessing doctors and students are important for the care of patients now and in the future. You should be willing to contribute to these activities.’

Unfortunately, the word ‘should’ can be interpreted in different waysand allows people out of teaching, but the message remains clear: teach, otherwise not only is psychiatry’s future jeopardised, but patient care also.

There are many ways of addressing this failure including mandatory teacher training and appraisal of teaching as part of CPD, dedicating one Programmed Activity to teaching in job plans and expanding the variety of Student Selected Components in psychiatry, to enthuse consultants and allow them to indulge special interests, but the collective will of the consultant body to change simply must be there.

Brown et al’s Sisyphean analogy was perfect and it will take people in positions of the most power and influence to overcome the mighty Zeus.

References:

1 Royal College of Psychiatrists. Dean’s Newsletter. Royal College ofPsychiatrists Website 2009; May (http://www.rcpsych.ac.uk/specialtytraining.aspx).

2 Brown N, Vassilas CA, Oakley C. Recruiting psychiatrists – A Sisyphean task? Psychiatric Bulletin 2009; 33: 390-92.

3 Eagles JM, Wilson S, Murdoch JM, Brown T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatric Bull 2007; 31: 70-2.

4 McParland M, Noble LM, Livingston G et al. The effect of a psychiatric attachment on students’ attitudes to and intention to pursue psychiatry as a career. Medical Education 2003; 37: 447-54.

5 General Medical Council. Good Medical Practice: Teaching and training, appraising and assessing. GMC Website 2009; Dec (http://www.gmc-uk.org/guidance/good_medical_practice/teaching_training.asp).
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�Green shoots� in Psychiatry Recruitment

Judith R Harrison, Medical Student
25 November 2009

Dear Editor,

Psychiatry has never been a popular specialty among British medical students, but recently recruitment has reached a critical juncture; only 6% of MRCPsych paper two candidates in 2008 were UK graduates.[1] Brown et al[2] give a comprehensive analysis of the factors contributing to the current crisis and discuss the attempts to remedy the situation.

Undergraduate experiences of psychiatry are crucially important in determining later career choices;[3] the College recognises this and should be commended for its efforts in the last year to promote the specialty. In addition to the new Student Associate Grade, launched in December 2008, the College has also staged a number of events, including an undergraduate conference, a Student Session at the Annual Meeting and even a Summer School. Furthermore, it has spearheaded the establishment of student Psychiatry Societies in medical schools across the country.

I am pleased to report that the recruitment campaign already appears to be having a positive impact. As a 5th year Medical Student and President of Dundee University Psychiatry Society, I attended the First Annual Meeting of Psychiatry Societies, sponsored by the Association of University Teachers in Psychiatry, on the 9th of November at Guy’s Hospital, London. The views of 14 university Psychiatry Societies were represented at the meeting, mostly by delegates present in person. It allowed us to share our ideas for successful events and discuss way to collaborate further in future.

It was apparent at the meeting that many students who attended the summer events returned to University in September to become active and enthusiastic members of their local societies, helping to promote Psychiatry and the Student Associateship to their colleagues. This is evidence of the success of the undergraduate events and highlights the potential of the Psychiatry Societies network as means of encouraging those who are already interested in the psychiatry and of attracting students who haven’t considered a career in the specialty.

These ‘green shoots’ must be nurtured to increase the numbers of UK doctors choosing psychiatry. The College should build on its progress to date by developing schemes to support Foundation Doctors thinking of entering psychiatry specialist training. Moreover, I endorse the view ofBrown et al[2] that, in addition to national efforts, all psychiatrists have an individual role to play in raising the profile of psychiatry amongmedical students. By acting as advocates for their specialty psychiatrists can cultivate the next generation of the profession.

1.Oxtoby K. Psychiatry in crisis. BMJ 2008; Classified suppl: 27 August.

2.Brown N., Vassilas C. A. & Oakley C. Recruiting Psychiatrists– a Sisyphean task? Psychiatr Bull 2009; 33: 390-392.

3.Eagles, J.M., Wilson, S., Murdoch, J.M., & Brown, T. What impact to undergraduate experiences have upon recruitment into psychiatry?Psychiatr Bull 2007; 31: 70-72.

Jude Harrison, 5th Year Medical Student and Student Associative Representative on the RCPsych Psychiatric Trainees’ Committee, Dundee University Medical School, Ninewells Hospital, Dundee. Email: judeharrison@doctors.org.uk.

Declaration of interest: None.
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First things first.

Salman A Mushtaq, Specialty Registrar
16 November 2009

Recruiting Psychiatrists is indeed a Sisyphean task. The authors mention the steps taken by the Royal College of Psychiatrists to engage more closely with college students (1). We couldn’t emphasise more, the importance of these measures, however there seems to be more fundamental problems, which needs addressing, which are likely to hinder the progress of these measures.

The college wants to ensure that the medical students are aware of the advantages of a career in psychiatry. Before we can do that, we have to first make the career in Psychiatry more attractive as currently even many Psychiatric trainees are struggling to convince themselves about the advantages of working in Psychiatry.

This is not to be confused with the intellectual stimulation and the challenges that the fascinating field of Psychiatry brings, as these are the reasons that attract doctors towards Psychiatry in the first place. Weare talking about the working environment, the increasing confusion about the role of Psychiatrists in Psychiatry?, the current state and future of Psychiatry, the new ways of working and the continuous dismissal of Psychiatry as a scientific field by the spin doctors and political gurus.

Providing better and flexible working environment in Psychiatry does not seem to be part of the government’s plan for the future of National health service as compared to other fields like General Practice(2). Most of the agendas that are damaging the reputation of Psychiatry and allowingpeople to question the existence of Psychiatry as a scientific field are politically driven, but the senior Psychiatrists of the country are also to blame for colluding with politicians and not doing enough to preserve the integrity of Psychiatry (3).

Training opportunities for junior trainees are being compromised by replacing out of hour on call rotas with other mental health professionals, purely to cut costs. Many trainees are struggling to get decent supervision, while some senior Psychiatrists are too busy training nurse prescribers. Nothing wrong with training other professionals but we need to get our priorities right. While the College and Schools of Psychiatry encourage higher trainees to get involve in medical education and recruit medical students, and there are many highly enthusiastic trainees willing to do this, the reality is that the new ways of working and the new training schemes provide very little opportunity and time to the trainees to undertake any such activities.

While we must continue to encourage people to join the most fascinating field of science, we also need to get the house in order.

Zeus may feel generous one day and lift the curse from Sisyphus, but the factors related to the curse looming over the British Psychiatry seemsfar stronger than the powers of Zeus.

References:

1.Brown N et al: Recruiting Psychiatrists – A Sisyphean task? Psychiatric Bulletin; 2009 33: 390-392.

2.Darzi L. High Quality Care for All: NHS Next Stage Review Final Report. Department of Health, 2008

3.Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P,et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6 –9.
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Psychiatric Recruitment: Mersey Experience

Mohammad S Rahman, ST5 in Forensic Psychiatry, Mersey Deanery
05 November 2009

Dear Editor,

Difficulty in recruiting psychiatrists had been a recurring theme in the UK [1], USA [2] and the other parts of the world. Brown et al [3] highlighted the difficulties in psychiatric trainee recruitment within thecontext of changing training structure in UK.

While there are reasons for concerns, we wanted to highlight our local experience which provides some grounds for optimism. In Mersey Deanery, in 2009, we recruited 19 Core Trainees (CT1), of which 9 (47%) were graduates of British medical schools. In 2008, we recruited 18 CT1s, of which 7 (39%) were from British medical schools. These are higher than the national and West Midland’s (25%) experience and comparable to some other specialities in medicine [4] .

We believe that there is a higher proportion of British medical graduates applying for these posts, which results in eventual higher recruitment. The School of Psychiatry in Mersey Deanery actively collaborates with the University of Liverpool to shape the undergraduate medical curriculum. Apart from 6 weeks clinical placement, medical students in their 3rd and 4th year also receive introductory and mental state examination tutorials and several sessions of case based Problem Based Learning (PBL) teaching. Mersey Deanery also allocated several 4 months Foundation Year (FY1 and FY2) posts to psychiatry, which are generally well received. Whether such visible and increased presence of psychiatrists during the pre and post registration period have a role to play in increasing recruitment, is yet to be clarified.

References:

[1] Goldacre MJ, Turner G, Fazel S, Lambert T. Career choices for psychiatry: national surveys of graduates of 1974-2000 from UK medical schools. British Journal Of Psychiatry 2005, 186, 158 - 164

[2] Sierles FS, Yager J, Weissman SH, Recruitment of U.S. Medical Graduates Into Psychiatry: Reasons for Optimism, Sources of Concern. Academic Psychiatry 2003; 27:252-259

[3] Brown N, Vassilas CA, Oakley C. Recruiting psychiatrists - a Sisyphean task? Psychiatric Bulletin 2009; 33: 390-392

[4] Goldacre MJ, Davidson JM, Lambert TW. Country of training and ethnic origin of UK doctors: database and survey studies. BMJ 2004; 329:597
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