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 The critical arguments are based on now-outdated ideas such as lobectomies and excessive use of electroconvulsive therapy, Reference Nasrallah3 yet the echoes of this continue to permeate popular culture as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
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
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.
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
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.
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.