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Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009

  • Michael J. Goldacre (a1), Seena Fazel (a2), Fay Smith (a3) and Trevor Lambert (a3)
Abstract
Background

Recruitment of adequate numbers of doctors to psychiatry is difficult.

Aims

To report on career choice for psychiatry, comparing intending psychiatrists with doctors who chose other clinical careers.

Method

Questionnaire studies of all newly qualified doctors from all UK medical schools in 12 qualification years between 1974 and 2009 (33 974 respondent doctors).

Results

One, three and five years after graduation, 4–5% of doctors specified psychiatry as their first choice of future career. This was largely unchanged across the 35 years. Comparing intending psychiatrists with doctors who chose other careers, factors with a greater influence on psychiatrists' choice included their experience of the subject at medical school, self-appraisal of their own skills, and inclinations before medical school. In a substudy of doctors who initially considered but then did not pursue specialty choices, 72% of those who did not pursue psychiatry gave ‘job content’ as their reason compared with 33% of doctors who considered but did not pursue other specialties. Historically, more women than men have chosen psychiatry, but the gap has closed over the past decade.

Conclusions

Junior doctors' views about psychiatry as a possible career range from high levels of enthusiasm to antipathy, and are more polarised than views about other specialties. Shortening of working hours and improvements to working practices in other hospital-based specialties in the UK may have reduced the relative attractiveness of psychiatry to women doctors. The extent to which views of newly qualified doctors about psychiatry can be modified by medical school education, and by greater exposure to psychiatry during student and early postgraduate years, needs investigation.

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Copyright
Royal College of Psychiatrists, This paper accords with the Wellcome Trust Open Access policy and is governed by the licence available athttp://www.rcpsych.ac.uk/pdf/Wellcome%20Trust%20licence.pdf
Corresponding author
Professor Michael J. Goldacre, UK Medical Careers Research Group, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK. Email: michael.goldacre@dph.ox.ac.uk
Footnotes
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See editorial, pp. 163-165, this issue.

Declaration of interest

None.

Footnotes
References
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3 Salsberg, E, Rockey, PH, Rivers, KL, Brotherton, SE, Jackson, GR. US residency training before and after the 1997 Balanced Budget Act. JAMA 2008; 300: 1174–80.
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13 Eagles, JM, Wilson, S, Murdoch, JM, Brown, T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull 2007; 31: 70–2.
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21 Katschnig, H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010; 9: 21–8.
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Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009

  • Michael J. Goldacre (a1), Seena Fazel (a2), Fay Smith (a3) and Trevor Lambert (a3)
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eLetters

Choice and rejection of psychiatry as a career: potential for change

Adam Hughes, Foundation Year 2 Doctor
15 August 2014

This study by goldacre et al. (1) is an excellent insight into the factors affecting career choice amongst medical students and can obviouslybe used to target areas for improvement to attract greater recruitment into psychiatry. It highlighted that the majority of students considering psychiatry disregarded the specialty due to 'job content' which I feel covers a broad spectrum of reasons. Appendix 2 from the paper showed examples of statements which included "unrewarding - difficult to make patients better". This was mirrored in study published in 2011 (2) which found that the most common factor for not pursuing a career in psychiatry was 'prognosis of patients in psychiatry'. I feel that there are a number of ways to potentially change this view of psychiatry patients having a generally poor prognosis. Medical student placements is an obvious place to start; students could be encouraged to engage with patients that are currently well and stable to explore their experience of mental illness. Longer attachments to a mental health team may allow for students involvement in long-term follow up. Also more placements in acute settings such as the emergency department or the crisis team would allow students to experience the acute management of patients. This may also dispel another reason given as an example in goldacre et. al "not challenging enough - pace too slow".

1.GOLDACRE, M.J., FAZEL, S., SMITH, F., LAMBERT, T. Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009. Br J Psychiatry 2013; 202: 228-34.

2.CURTIS-BARTON MT, EAGLES JM. Factors that discourage medical students from pursuing a career in psychiatry. Psychiatrist 2011; 35: 425-9.

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Conflict of interest: None declared

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Choice of Psychiatry as a career: Importance of student placements

Kapil Bakshi, Consultant Psychiatrist
03 April 2013

The findings by Goldacre,et al(1) do not bode well for the future of recruitment in psychiatry.

The Royal college of psychiatrists recruitment strategy(2) aims to use a multi-pronged approach to deal with the recruitment crisis.At local level, the psychiatrists hold responsibility to act as ambassadors, promoters and role models to attract enthusiastic medical students and trainees into the profession.

Various studies have highlighted that interest in psychiatry is fairly high among sixth formers(3) and medical school entrants but decays over time. Personal experience suggests that medical students have great degree of appreciation for the holistic model of psychiatry. We believe that designing placements with motivated trainers which offer positive experience are imperative to nurture this enthusiasm.

In the study, 71% respondents cited 'job content' as a reason to reject psychiatry. In another survey, Goldacre et al (4) found that careerchoices were greatly influenced by experience of the chosen subject as a student and by a particular teacher.The undergraduate students get reasonable exposure to psychiatry in their training but trainers need to ensure that the placements are of high quality. Placements during medical school and foundation year offer great opportunity to showcase psychiatry as a modern, scientific speciality collaborating closely with non-medical disciplines to offer holistic care to patients. The trainers need to ensure that placements highlight and emphasise neurodevelopment models, evidence base for psychological treatments and innovative service deliverywhich offer more care in the community. The demonstration of robust risk management strategies and positive outcomes will go a long way in dispelling myths associated with the profession and our patients.

The importance of positive role modelling through enthusiastic, motivated trainers can not be overemphasised.

References:

1. GOLDACRE, M.J., FAZEL, S., SMITH, F., LAMBERT, T. Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009. Br J Psychiatry 2013; 202: 228-34.

2.Royal College of Psychiatrists. Recruitment Strategy 2011-2016. Royal College of Psychiatrists, 2012.

3.MAIDMENT, R., LIVINGSTON, G., KATONA, M., et al (2003) Carry on shrinking: career intentions and attitudes to psychiatry of prospective medical students.Psychiatric Bulletin, 27, 30- 32.

4.GOLDACRE, M. J., TURNER, G. & LAMBERT, T. W. (2004) Variation by medical school in career choices of UK graduates of 1999 and 2000. Medical Education, 38,249- 258.

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Conflict of interest: None declared

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Choice of Psychiatry as a Career: the Indian experience

Preeti Parakh
22 March 2013

Dear Sir,

The paper by Goldacre et al (1), describing the choice and rejection of psychiatry as a career by medical graduates in the United Kingdom, was an interesting read. We would like to share our experience from India, which is both similar and different to the findings from the United Kingdom.

Like the UK, India also suffers from a shortage of psychiatrists, with only a few thousand psychiatrists available to cater to a population of more than one billion. The average national deficit of psychiatrists is77% with high variations across the country. Some cities have a surplus ofpsychiatrists while many predominantly rural areas have a deficit of more than 90% (2). In the UK, historically, more women than men have chosen psychiatry with the gap closing in (1), but in India, women constitute only 15% of the total number of psychiatrists and the number is rising (3). In a study of Indian medical students, 3.9% of senior medical students considered psychiatry as their first choice for future specialization (4), which is comparable to the rate reported by Goldacre et al (1). The same study (4) also reported that student experience of psychiatry was influential in career choice of psychiatry, as also seen inthe study by Goldacre et al (1).

The medical education system in India differs from that in the UK in the method of admission to post-graduate courses. In India, after graduation, medical students sit for a highly competitive national entrance examination for post-graduate seats and get to choose their specialty on the basis of the rank secured in the entrance examination andthe seats available at the rank. Hence, unlike in the UK, for many Indian medical students, initial career choices may not translate into eventual career destinations. However, in spite of the differences in the medical education systems, the suggestions given by Goldacre et al1 to improve recruitment into psychiatry may be applicable in other countries as well, including India.

Yours sincerely,

Preeti Parakh, Debasish Basu

References1.Goldacre MJ, Fazel S, Smith F, Lambert T. Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009.Br J Psychiatry 2013; 202: 228-34.2.Thirunavukarasu M, Thirunavukarasu P. Training and national deficit of psychiatrists in India - a critical analysis. Indian J Psychiatry 2010; 52: S83-8.3.Sood M, Chadda RK.Women psychiatrists in India: a re?ection of their contributions. Indian J Psychiatry 2010; 52: 396-401.4.Alexander PJ, Kumaraswamy N. Impact of medical school experiences on senior medical students' interest in psychiatry. Indian J Psychiatry 1995;37: 31-4.

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Conflict of interest: None declared

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Letter re: Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009

Mallika Punukollu, Specialist Registrar CAMHS
22 March 2013

I found Goldacre et al's paper very interesting. I agree with previous studies that highlighting a medical model for psychiatry would promote more recruitment into psychiatry (1) (2) such as introducing more neurology into the curriculum as part of our training. I believe Psychiatry requires a clear identity which it is currently lacking, a large proportion of the public do not know that psychiatrists are doctors and think that our work consists mainly of counselling (3). A clear distinction needs to be made that psychiatry is a medical speciality and one area that would be interesting to study further is if Psychiatry couldbenefit from a rebranding; to be renamed neuropsychiatry rather than psychiatry for example. One of the reasons cited by students in the study for not choosing Psychiatry included lack of prestige and respect from peers. To address this as psychiatrists I think being more involved and contributing to multidisciplinary meetings between the specialities may improve peer perceptions of psychiatry. I found interesting that students cited perceived violence from patients as a reason to not pursue Psychiatry, statistics show there is a greater degree of aggressive patients that comeinto Accident and Emergency departments (4) however Emergency medicine remains a more popular choice of speciality than psychiatry (5). It may bethat Psychiatry trainees and students require more support in situations perceived as threatening which may be more readily available in other specialities. Students also cited poor experiences in the speciality; ithas become a vicious cycle that with less recruitment psychiatry jobs havebecome more service oriented with less time for teaching, training and research creating low morale. Until the balance is addressed recruitment and retention into psychiatry will continue to decline.

References1.Craddock N, Antebi D, Attenburrow M-J, Bailey A, Carson A, Cowen P et al. . Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6-9

2.S?nderg?rd L. . Recruitment problems in psychiatry: just a matter of more exposition? Acta Psychiatr Scand 2007; 116: 235-7.

3.Williams A, Cheyne A, MacDonald S. The public's knowledge of psychiatrists: questionnaire survey. The Psychiatrist (2001)25: 429-432doi:10.1192/pb.25.11.429

4.Health and Safety Commission Advisory Committee (1997)Violence AndAggression to Staff in the Health Service. London: HSC Books.

5.Heard S. (2006) Choosing your hospital specialty. BMJ Career Focus307(Suppl):221.

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Conflict of interest: None declared

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