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Psychiatry – recruitment crisis or opportunity for change?

Published online by Cambridge University Press:  02 January 2018

Helen Henfrey
Affiliation:
West Yorkshire Deanery, UK. Email: helen.henfrey@nhs.net
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Summary

Psychiatry is suffering an enduring crisis in recruitment. In this editorial I discuss the reasons for this that are most pertinent to recruitment from foundation training and also review the Royal College of Psychiatrists' current 5-year plan for recruitment and what else could be done.

Type
Editorials
Copyright
Copyright © Royal College of Psychiatrists, 2015 

Introduction

The ‘crisis’ of recruitment into psychiatry at the level of core training is of both historical and contemporary relevance. In 2012 only 78% of core training year 1 posts in psychiatry were filled and psychiatry continues to be quoted as a ‘recruiting, not a selecting, specialty’. Reference Mukherjee, Maier and Wessely1 In addition, psychiatry core training consistently fails to attract British graduates Reference Mukherjee, Maier and Wessely1 and much of the deficit is met by graduates from overseas. This is despite a call from the Royal College of Psychiatrists describing the clear benefits of clinical staff who have experience of British culture. Reference Brown2 Preceding literature documents the decline in enthusiasm for psychiatry during undergraduate education and the multitudes of reasons for this have also been described. This editorial does not profess to discuss all the reasons for this trend, instead it aims review those most applicable in terms of recruitment from foundation training. At this the midpoint of the Royal College of Psychiatrists' 5-year recruitment policy it is also pertinent to discuss the strategies being employed currently, and what else could be done to reverse this trend.

Community and professional stigma

Psychiatry is unique among other specialties in that it has its own ‘nemesis’ in the form of the ‘antipsychiatry movement’. Reference Nasrallah3 The antipsychiatry debate has been active for over two centuries and continues to vocally criticise psychiatry despite the many advances in treatments now available. The critical arguments are based on now-outdated ideas such as lobectomies and excessive use of electroconvulsive therapy, Reference Nasrallah3 yet the echoes of this continue to permeate popular culture as can be witnessed by the many films and books on the subject. This stealthy infiltration of social and cultural norms cannot be underestimated in its effects on potential clinicians and goes some way to explain the findings of a recent survey. In 2013 St George's University of London researchers found that 47% of the public would be ‘uncomfortable sitting next to a psychiatrist at a party’. 4 In addition 60% of the public believed that ‘psychiatrists know what you are thinking’ and over half of the public did not realise a psychiatrist had a medical degree. 4 Potential recruits to psychiatry are not unaided when making their career decisions and are influenced by their friends, families and social norms. All of this suggests an unfriendly cultural atmosphere in terms of choosing psychiatry as a career, highlighted by evidence from Canada suggesting that negative comments from ‘friends and family about choosing psychiatry was a deterrent’ when surveying a cohort of psychiatry trainees. Reference Wiesenfeld, Abbey, Takahashi and Abrahams5

Compounding the unfavourable cultural misconceptions of psychiatry are those that originate from within the medical community. Negative comments from non-psychiatrist colleagues regarding the specialty are especially detrimental and this has become regarded as a source of stigmatisation against psychiatrists. Reference Bassiri, Lyons and Hood6 It is, however, pleasing to see that those same psychiatrists have a high level of satisfaction with their work and there was no evidence of ‘self-stigma’, despite the apparent discriminatory attitudes towards them. Reference Bassiri, Lyons and Hood6 Extrapolating this to medical students a study of 580 students in Australia found that those interested in pursuing a career in psychiatry were less influenced by prestige within the medical community. Reference Malhi, Coulston, Parker, Cashman, Walter and Lampe7 Conversely, therefore, it could be suggested that those influenced by prestige within the medical community are less likely to chose psychiatry as a specialty. This in turn cannot be overlooked when considering barriers to recruitment.

The solution so far

It has been suggested that to attract future psychiatrists the role and perception of psychiatry needs rebranding. Reference Volpe, Boydell and Pignatiello8 Perhaps with this in mind the Royal College of Psychiatrists is undertaking a major project to increase interest in psychiatry as a career for individuals ranging from sixth-form students to foundation doctors. Over 5 years from 2011 to 2016 the College aims to increase applications to core training by 50%. Reference Brown2

School students

The Royal College of Psychiatrists aims to increase access to work experience placements for senior school pupils with the goal of attracting individuals from the earliest possible time in its 5-year recruitment plan. Reference Brown2 Information days have also been demonstrated as opportunities for recruitment into training schemes in Canada. Reference Wiesenfeld, Abbey, Takahashi and Abrahams5 Perhaps in view of this the Royal College of Psychiatrists proposes to organise lectures, educational workshops and career fairs focusing on psychiatry for school pupils. Reference Brown2

Medical students

A systematic review of attitudes of medical students towards psychiatry as a career suggested that innovative teaching strategies needed to be developed, in addition to more attention being focused on the psychiatry curriculum. Reference Lyons9 Echoing this the Royal College of Psychiatrists proposes to increase the number of ‘special study components’ in psychiatry, in addition to facilitating medical school psychiatry societies. Reference Brown2 The College further proposes to increase numbers of student associates, integrate psychiatry further into the curriculum and to develop a database of electives. Reference Brown2 The College has also been involved with a number of ‘psychiatry summer schools’ over recent years.

Foundation doctors

The development of the foundation training scheme for new graduates in the UK aimed to provide more experience of different specialties. 10 The scheme involves rotating through six different specialties over the course of 2 years after graduation. In relation to this it has been shown that experience of a specialty increases the likelihood of a future career within that field. Reference Wiesenfeld, Abbey, Takahashi and Abrahams5 Yet, only 16% of foundation trainees in 2012 had the experience of a psychiatry post, regardless of the larger potential for possible positions. 11 Foundation trainees also have the opportunity to undertake ‘taster days’ in those specialties in which they may be interested in pursuing a future career. In 2012, 3% of foundation year 1 (FY1) tasters were undertaken in psychiatry and 6.3% of FY2 tasters. In comparison 22.7% of FY1 and 23.4% of FY2 tasters were taken in medical specialties. 11 This indicates a vastly underused resource in terms of providing experience to foundation trainees that may increase the likelihood of them choosing psychiatry as core trainees. However, the reasons behind the low take-up of taster days may lie in the community and professional stigmas associated with psychiatry, as discussed above. Both an increase in foundation posts in psychiatry and the promotion of more taster days are supported by the Royal College of Psychiatrist's 5-year recruitment strategy. Reference Brown2 In addition the College recommends the development of e-learning tools for foundation doctors unable to undertake a placement in psychiatry and supports ‘broad-based training schemes’ that integrate time spent in psychiatry. Reference Brown2

Stigmas

As outlined above, negative comments from other clinicians can have a detrimental effect on potential candidates for recruitment. The College supports ‘a ‘zero tolerance policy’ towards stigmatising attitudes from other doctors’ and is planning on liaising with other professional bodies to address this. Reference Brown2

Solutions – the future?

It is my view that the College's 5-year recruitment strategy addresses many of the barriers to recruitment that face psychiatry today. There is, however, still work to be done to alter fundamental attitudes based mainly on community stigma. Campaigns running currently, such as ‘Time to Change’, are making steps to address and challenge the stigma and discrimination experienced by people with mental health problems. 12 In terms of altering community opinion great work has been done by well-known individuals promoting their own difficulties with mental illness. Such ‘celebrity endorsement’ of mental health services may go some way to address the social stigma against both psychiatric patients and the people who work with them. An advertising campaign in New Zealand showed that the involvement of celebrity experiences of mental illness increased public awareness and improved attitudes. Reference Vaughan and Hansen13 In terms of discrimination against psychiatrists originating from within the medical community more could be done to promote the reality of evidence-based psychiatric practice. This could be achieved by integrating psychiatric research into work done in other specialties (for example dementia and geriatric medicine) with the aim of creating stronger bonds between psychiatry and other specialties. Clear evidence exists of the high levels of satisfaction with their work that many psychiatrists report; Reference Bassiri, Lyons and Hood6 this should also be more clearly emphasised to potential recruits.

The future

Only time will reveal the results of the 5-year recruitment strategy instigated by the Royal College of Psychiatrists. The aim, however, is clear – to encourage high-quality applicants to join a dynamic and evolving specialty. This can only be achieved by a united psychiatric community working to promote the specialty in both the public perception and within the medical community.

References

1 Mukherjee, K, Maier, M, Wessely, S. UK crisis in recruitment into psychiatric training. Psychiatrist 2013; 37: 210–4.CrossRefGoogle Scholar
2 Brown, T. Recruitment Strategy 2011-2016. Royal College Psychiatrists, 2012 (http://www.rcpsych.ac.uk/pdf/Recruitment%20Strategy%20-%2010092013.pdf).Google Scholar
3 Nasrallah, H. The antipsychiatry movement: who and why. Curr Psychiatry 2011; 10: December (http://www.currentpsychiatry.com/index.php?id=22661&tx_ttnews[tt_news]=176468).Google Scholar
4 Royal College Psychiatrists. Misconceptions about Psychiatrists ‘Common’ among Public and Medical Students. Royal College Psychiatrists, 2013 (http://www.rcpsych.ac.uk/mediacentre/pressreleases2013/psychiatristsrole.aspx).Google Scholar
5 Wiesenfeld, L, Abbey, S, Takahashi, SG, Abrahams, C. Choosing psychiatry as a career: motivators and deterrents at a critical decision-making juncture. Can J Psychiatry 2014; 59: 450–4.CrossRefGoogle Scholar
6 Bassiri, M, Lyons, Z, Hood, S. Stigmatisation of psychiatrists: experiences of psychiatrists and psychiatric registrars in Western Australia. Educ Res Perspect 2011; 38: 3544.Google Scholar
7 Malhi, GS, Coulston, CM, Parker, GB, Cashman, E, Walter, G, Lampe, LA, et al. Who picks psychiatry? Perceptions, preferences and personality of medical students. Aust N Z J Psychiatry 2011; 45: 861–70.CrossRefGoogle ScholarPubMed
8 Volpe, T, Boydell, KM, Pignatiello, A. Choosing child and adolescent psychiatry: factors influencing medical students. J Can Acad Child Adolesc Psychiatry 2013; 22: 260–7.Google ScholarPubMed
9 Lyons, Z. Attitudes of medical students toward psychiatry and psychiatry as a career: a systematic review. Acad Psychiatry 2013; 37: 150–7.CrossRefGoogle ScholarPubMed
11 The UK Foundation Programme Office. Foundation Programme Annual Report 2012. UK Foundation Programme Office, 2013 (http://www.foundationprogramme.nhs.uk/pages/home/keydocs).Google Scholar
12 Time to Change. About. Time to Change, no date (http://www.time-to-change.org.uk/about).Google Scholar
13 Vaughan, G, Hansen, C. ‘Like Minds, Like Mine’: a New Zealand project to counter the stigma and discrimination associated with mental illness. Australas Psychiatry 2004; 12: 113–7.Google ScholarPubMed
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eLetters

Looking inwards to make a difference

18 August 2015
Nadim Almoshmosh, Consultant Psychiatrist, Priory Group
Dr Henfrey’s editorial is timely and rightly focuses on some important factors affecting recruitment into psychiatry. Despite the College various efforts so far we still talk about “recruitment, not a selecting specialty”. Besides the community and professional stigma as barriers to recruitment there is in, my view, another important factor to be taken into account, that is from within. Psychiatry... More
Conflict of interest: None Declared

Re. Psychiatry- recruitment crisis or opportunity for change?

09 August 2015
Sophie Behrman, ST5 General/Older Adult Psychiatry, Oxford Health NHS Foundation Trust
I read Dr Henfrey’s editorial (1) with great interest. I am pleased that the 5 year recruitment plan is receiving due recognition towards the end of its existence. However, I would argue that 5 years is not long enough to reap the benefits of the recruitment drive. The recruitment plan is three pronged: addressing school students, medical students and foundation doctors. I would argue that the most... More
Conflict of interest: None Declared

Global Relevance of Recruitment Crisis in Psychiatry

31 July 2015
K.A.L.A. Kuruppuarachchi, Senior Professor of Psychiatry, Faculty of Medicine, University of Kelaniya, Sri Lanka
The editorial on Psychiatry – recruitment crisis or opportunity for change? ( Henfrey 2015) has been read with interest. Even though the author has focused mainly on the current situation in the U.K. , we believe that it has a global relevance. Obviously stigma towards psychiatry and psychiatrists has been existing for centuries. This area has been addressed /discussed extensively all over the world.... More
Conflict of interest: None Declared

Might more than 'rebranding' be required?

20 July 2015
Jonny Martell, CT1 psychiatry trainee, Chase Farm Hospital
Henfrey’s editorial offers a cogent review of the profession’s enduring recruitment crisis. However, her depiction of community and professional stigma is puzzling and complacent. To portray the profession’s nemesis as the antipsychiatry movement, misleadingly portrayed as arguments ‘based on now-outdated ideas such as lobectemies and excessive use of electoconvulsive therapy,’ ignores more contemporaneous... More
Conflict of interest: None Declared

The Psychiatry Early Experience Programme: an innovative teaching strategy to aid recruitment?

18 July 2015
Clare Holt, CT1 Psychiatrist, South London and the Maudsley Core Training Programme
Dear Editor: As core trainees in psychiatry Helen Henfrey’s editorial provided a welcome source of debate [1]. For us psychiatry was a positive choice, not a back-up plan. However, we are well aware of the challenges to recruitment in psychiatry [2]. Most of us can identify on a personal level with the issues raised in the editorial about the negative attitudes towards psychiatry from other doctors... More
Conflict of interest: None Declared

Rebranding is not enough

10 July 2015
Jennifer L Burgess, Final Year Medical Student, St George's, University of London
The Royal College strategy seems entirely focused on ‘rebranding’. If psychiatry could only change its image, then people would be interested. But Goldacre et al (2013) found that 71% of doctors who considered psychiatry but rejected it in favour of another speciality gave ‘job content’ as the primary reason. What is it about psychiatry that is so off-putting? The article gave some verbatim examples:... More
Conflict of interest: None Declared

Re: Psychiatry – recruitment crisis or opportunity for change?

09 July 2015
Kelvin Leung, FY2, South Tees Hospitals NHS Foundation Trust
Dear Editor, Stigmatisation toward mental illness has been a long established problem amongst the general public – throughout history, across cultures and even before modern diagnostic categories were constituted(1). The general public has, largely if not completely, been influenced by how psychiatric illnesses and treatments are portrayed in popular culture. Certain stereotypes circulate based on... More
Conflict of interest: None Declared

We Need More Friends in Psychiatry

09 July 2015
Itoro Udo, Consultant Psychiatrist (Locum), Broadoak Unit, Liverpool
The editorial by H. Henfrey [1] has generated interesting conversations this week. She has presented a well thought out review of the problem of recruitment into psychiatry, identifying barriers to improving recruitment among junior colleagues. I write to discuss a few thoughts. She has stated how often our adversaries maybe within the profession itself. [1] Her thoughts echo the thoughts expressed... More
Conflict of interest: None Declared

Psychiatry in the Foundation programme: opportunities and challenges

08 July 2015
Gopinath Ranjith, Consultant Liaison Psychiatrist, South London and Maudsley NHS Foundation Trust
The editorial by Helen Henfrey1 discusses the Foundation programme as one of the key points of intervention in efforts to enhance recruitment into psychiatry. She is right to point out that historically the number of Foundation posts in psychiatry has been very low. Fortunately this is changing, the main driver for the change being the report ‘Broadening the Foundation Programme’ (2014)2. By an explicit... More
Conflict of interest: None Declared

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