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Psychiatry – recruitment crisis or opportunity for change?

  • Helen Henfrey (a1)
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.

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References
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1 Mukherjee, K, Maier, M, Wessely, S. UK crisis in recruitment into psychiatric training. Psychiatrist 2013; 37: 210–4.
2 Brown, T. Recruitment Strategy 2011-2016. Royal College Psychiatrists, 2012 (http://www.rcpsych.ac.uk/pdf/Recruitment%20Strategy%20-%2010092013.pdf).
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).
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).
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.
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.
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.
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.
9 Lyons, Z. Attitudes of medical students toward psychiatry and psychiatry as a career: a systematic review. Acad Psychiatry 2013; 37: 150–7.
11 The UK Foundation Programme Office. Foundation Programme Annual Report 2012. UK Foundation Programme Office, 2013 (http://www.foundationprogramme.nhs.uk/pages/home/keydocs).
12 Time to Change. About. Time to Change, no date (http://www.time-to-change.org.uk/about).
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.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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Psychiatry – recruitment crisis or opportunity for change?

  • Helen Henfrey (a1)
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eLetters

Looking inwards to make a difference

Nadim Almoshmosh, Consultant Psychiatrist, Priory Group
18 August 2015

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 as a specialty continues to be less well defined than other medical specialties, understandably, as psychiatry deals with the person as a whole, body and mind. This comes with some complexities particularly when there is little in terms of tests to confirm diagnoses. Therefore the clinical opinion of the treating psychiatrist often is the main drive when it comes to making a diagnosis and devising the medical management of mental disorders. Here psychiatrists can vary widely on their views on these two important areas for doctors, diagnosis and treatment. I was a College Tutor and an Educational Supervisor for Foundation Years trainees for a number of years and I listened to their feedback. For the observing new comers or potential recruits these conflicting views expressed on often the same conditions do not go down well in terms of attraction to the specialty. It can give the impression that psychiatrists do not seem to agree on diagnosing or managing common conditions. For the indecisive candidate this is not very encouraging sign.

For me, psychiatrists should do more to help define our specialty to show what we good at and why no one else can do it better than us. The psychiatrist, over time and not to undermine the value of team work, is looked at as a team member only with a role that is sometimes difficult to distinguish from other MDT members. This can be seen as we are slowly allowing ourselves to be less distinguished even in within our own teams. Therefore new doctors and potential recruits who are influenced by the “prestige” of the medical profession will I guess be less interested in the specialty.

Psychiatry is an art that should involve clear communication and we hear this all the time but unfortunately it does not always feature in our practice. Amid all these complexities of our specialty, psychiatrists should always document and state clear reasons on why we do things the way they do them. For example, a psychiatrist’s impression, should state the diagnosis is made because of the following psychopathology/symptoms and signs and that is based on a particular disorder classification. This clarity and reasoning can make a difference in helping trainees and other professionals understand the rational and the process followed for decisions we make. Naming things in a simple way can go a long way to make others understand what we say and do.

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Conflict of interest: None Declared

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Re. Psychiatry- recruitment crisis or opportunity for change?

Sophie Behrman, ST5 General/Older Adult Psychiatry, Oxford Health NHS Foundation Trust
09 August 2015

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 powerful impact can be had on the former, and that any changes here will take at least 9 years to come into effect (by the time the students have achieved A-levels, attended medical school, completed foundation jobs and applied for core training).

I have been running a work experience programme for 17+yr olds applying to medical school (www.psychedupformedicalschool.org) and have been amazed by how one week’s experience can change their attitude towards psychiatry, mental health and their career plans (2). As part of the project I have become interested in what the cohort see as priorities for their career. Data I have collected suggest that brain-science and research, opportunities for flexibility within a career and teamwork tend to be high on their agendas. The students tend to be surprised that these features are all common to psychiatry, having a very Freudian view of what a psychiatrist does. Psychiatry, is therefore in an excellent state to “sell” itself to students at this early stage. The specialism will remain on their radar through medical school and the early years of their careers. A further benefit of starting young is that the students may progress to address stigma, first amongst peers in school (a key target group from the Changing Minds strategy (3)), and then from the “bottom up” in medical school, when, as they have had tangible experience of psychiatry before their peers they may be in a good position to address misunderstandings and negative attitudes.

There are shortages of work experience placements for students applying to medical school, particularly in psychiatry (4). It would seem that would-be psychiatrists tend to have considered the career before medical school (5), therefore recruitment strategies aimed at medical students and foundation doctors may be less influential. I would urge other psychiatrists to set up work experience schemes locally and am very happy to support other projects- please get in touch (sophie.behrman@doctors.org.uk).

(1) Henfrey, H. Psychiatry- recruitment crisis or opportunity for change? British Journal of Psychiatry 2015; 207: 1-2

(2) www.psychedupformedicalschool.org

(3) Crisp A, Gelder M, Goddard E, Meltzer H. Stigmatization of people with mental illnesses: a follow up study with the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry 2005. 4 (2) 106-113

(4) Albert A M, Raoof A. Availability of work experience placements in psychiatry: the real picture. Psychiatric Bulletin 2014; 38(6): 306

(5) 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. BJPsych 2013 202:228-234

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Global Relevance of Recruitment Crisis in Psychiatry

K.A.L.A. Kuruppuarachchi, Senior Professor of Psychiatry, Faculty of Medicine, University of Kelaniya, Sri Lanka
Chirantha S. Kuruppuarachchi, Medical Student, South Asian Institute of Technology and Medicine, Malabe, Sri Lanka
31 July 2015

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. Discrimination of psychiatrists and the field within the profession as well as amongst the other colleagues has been a universal phenomenon and a major issue. Challenges to the field including decrease confidence about the knowledge , shortage of a proper theoretical basis and external challenges such as competition from other professions , patients dissatisfaction and negative image have been pointed out(Katschnig 2010). Also psychiatrists seem to have an identity crisis. Obviously similar factors could negatively affect the undergraduates as well.

It is interesting to note that the article tries to highlight the feelings/views about psychiatrists by the public and also the hostile socio-cultural factors which can adversely influence the recruitment potential.

Even in countries like Sri Lanka the importance of improving undergraduate psychiatric education has been emphasized ( Kuruppuarachchi & De Silva 2014). The factors influencing the recruitment potential and carrier choice seem to be essentially similar to the west.

As mentioned in the article it is necessary to integrate psychiatry into the other disciplines. We need to concentrate on ways of improving liaison work too. If we are able to improve the knowledge of psychiatry amongst the undergraduates , then they can act as messengers to reduce the stigma towards psychiatry( whichever the discipline selected) as poor knowledge could exacerbate stigma and fear. This endeavor will also help to attract the good quality graduates to the field who are respected by the rest of the non psychiatric colleagues which will further help to improve the outlook of psychiatry.

The Royal Colleges, Psychiatric societies and Colleges and Psychiatric departments in medical schools globally have a crucial role to play with regard to this important area.

We also believe that the time has come to focus more on the positive aspect of psychiatry and to do more research work on the positive outcomes/aspect to improve the image of psychiatry.

References;

Henfrey H. Psychiatry – recruitment crisis or opportunity for change? British Journal of Psychiatry 2015; 207: 1-2.

Katschnig H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010; 9(1) : 21-28.

Kuruppuarachchi KALA , de Silva NR. Burden of mental illness and the need for better undergraduate education in psychiatry. Ceylon Medical Journal 2014; 59(2): 35-38.

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Might more than 'rebranding' be required?

Jonny Martell, CT1 psychiatry trainee, Chase Farm Hospital
20 July 2015

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 and pressing ‘critical arguments.’ The last Maudsley debate, published in the BMJ(1), found in favour of the motion that psychiatry is failing in that most basic ethical duty- primum non nocere. The heated exposure of conflicts of interest on both sides of the panel led to a less than favourable comparison of our academics’ corner-fighting antics to that of our political class in the national press the following morning(2).

‘The many advances in treatment,’ which might muffle the profession’s vocal critics are well qualified in a New York Times editorial last week by Weill Cornell Psychiatry Professor Richard Freeman(3). He writes, ‘with few exceptions, every major class of current psychotropic drugs.. basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.’

How much ‘reality of evidence-based psychiatric practice’ should we offer ‘in tackling discrimination within the medical community’? Perhaps not the 2006 study that reviewed every trial of psychiatric drugs in four academic journals over a ten year period (n=542) (4). Favorable outcomes were significantly more common in studies sponsored by the drug manufacturer (78%) than in studies without industry sponsorship (48%) or sponsored by a competitor (28%). Indeed, as the authors conclude, ‘further research is needed to elucidate the mechanisms underlying this relationship.’

A more humble appraisal of the product’s difficulties would be bitter medicine but perhaps better than a punchy marketing strategy. Might more than ‘rebranding’ be required to tackle psychiatry’s long-standing recruitment woes?

References:

(1) BMJ; 2015;350:h2435

(2) http://www.theguardian.com/commentisfree/2015/may/14/psychiatrists-argue-taking-antidepressants

(3) http://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?rref=collection%2Fcolumn%2Frichard-a-friedman&action=click&contentCollection=opinion®ion=stream&module=stream_unit&contentPlacement=1&pgtype=collection

(4)Psychol Med. 2006 Nov;36(11):1647-56. Epub 2006 Aug 8.

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

Clare Holt, CT1 Psychiatrist, South London and the Maudsley Core Training Programme
Ross Mirvis, CT1 Psychiatrist, South London and the Maudsley Core Training Programme
Helen Hutchings, CT2 Psychiatrist, South London and the Maudsley Core Training Programme
18 July 2015

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 – sentiments such as “why would you do that” or “what a waste, you are such a good doctor”.

Dr. Henfrey identifies the undergraduate period as a crucial time when enthusiasm for psychiatry may wane. While clinical attachments may improve attitudes towards psychiatry, this effect is often transient [3]. Also, during clinical placements face-to-face contact with psychiatrists can be variable as is students’ exposure to the sub-specialties. The editorial emphasises in particular the need for “innovative teaching strategies” and also the importance of greater integration of psychiatry into the curriculum. With these factors in mind we would like to present our own initiative – the Psychiatry Early Experience Programme (PEEP), which we believe meets both these aims.

PEEP was first introduced at King’s College London in 2013. The premise is that 1st year undergraduate medical students are paired with volunteer psychiatry trainees and shadow them at work, including when on-call. The recommendation is that students spend two days with their paired trainee every six months. Students are encouraged to remain in PEEP throughout medical school, providing regular exposure to psychiatry and a broad experience of its sub-specialties. It is hoped that PEEP will help to maintain more consistently positive attitudes towards psychiatry and also enable students to see first-hand the “high levels of satisfaction” psychiatrists have with their work that is cited in the editorial.

In September 2015 PEEP will enroll its third cohort of undergraduate medical students and there are also plans to extend the scheme to Sheffield University. PEEP is therefore aimed at British graduates and, as highlighted by Dr. Henfrey, it is this group that is a particular target in terms of increasing recruitment into psychiatry. In order to more objectively assess the effect of PEEP we are measuring students’ attitudes towards psychiatry on an annual basis using the validated 30-point attitudes towards psychiatry questionnaire (ATP-30) [4]. This is clearly an on-going project, but initial data are promising.

Finally, we want to make clear that PEEP is not only about recruitment and does not aim to convert all participants into psychiatrists. We hope that students enrolled in PEEP will develop both a more well-rounded and sensitive view towards psychiatry patients and a better understanding of the work done by psychiatrists. Thus we propose that initiatives like PEEP have a role to play in reducing the stigma faced not only by psychiatrists, but also more importantly by our patients. We welcome further correspondence from those interested in the scheme.

studentpeep@hotmail.co.uk

References:

1. Henfrey, H. 2015. Psychiatry – recruitment crisis or opportunity for change?. Br J Psychiatry 207:1-2

2. Brockington IF, Mumford DB. 2002. Recruitment into psychiatry. Br J Psychiatry, 180(4):307-12

3. Qureshi H, Carney S, Iversen A. 2013. Narrative review of the impact of clinical attachments on attitudes to psychiatry. The Psychiatrist Online, 37:104-110

4. Burra P et al. 1982. The ATP-30 – a scale for measuring medical students’ attitudes to psychiatry. Medical Education, 16(1):31-38

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