Poor recruitment of doctors into psychiatry in the UK has recently been described as a ‘crisis’, highlighted by the dwindling numbers of graduates from British universities sitting the MRCPsych exam. Reference Oxtoby1 The issue is not a new one in that for many years psychiatry has failed to attract adequate recruits both in the UK and elsewhere. Reference Brockington and Mumford2-Reference Sierles and Taylor4 Factors underlying this recruitment problem are complex and are likely to include medical student selection, undergraduate exposure to the specialty, postgraduate experiences and wider issues such as the public and professional image of psychiatry and psychiatrists. Reference Oxtoby1-Reference Balon, Franchini, Freeman, Hassenfeld, Keshavan and Yoder9 This paper will focus predominantly on factors arising during medical student training.
With only a few exceptions, studies have found that students’ attachments/clerkships in psychiatry give rise to more positive attitudes towards the specialty. Reference Calvert, Sharpe, Power and Lawrie10-Reference McParland, Noble, Livingston and McManus15 It is simplistic, however, to equate more positive attitudes with necessarily an increased likelihood of pursuing a psychiatric career, Reference Balon, Franchini, Freeman, Hassenfeld, Keshavan and Yoder9,Reference Sajid, Khan, Shakir, Moazam-Zaman and Ali16,Reference Balon17 and this likelihood does appear to decrease as medical students go through their training. Among sixth-form school pupils who were prospective medical students, for those stating a career intention, psychiatry was the fourth most popular choice. Reference Maidment, Livingston, Katona, Whitaker and Katona18 In contrast, it is among the least popular of clinical specialty choices made by medical students. Reference Rajagopal, Rehill and Godfrey19,Reference Gowans, Glazier, Wright, Brennels and Scott20 Although some of this difference may be explicable in terms of the type of school student who applies successfully to medical school, the change also suggests that factors are at play during the medical student years that reduce enthusiasm for a career in psychiatry. The nature of these factors is incompletely understood, and little is known as to how and when they might emerge during undergraduate training. The current study investigated some of these factors in the hope that this might lead to rational approaches towards enhancing recruitment into psychiatry.
From the existing literature, a questionnaire was designed to investigate medical students’ views about: (a) psychiatry and psychiatrists; (b) role models; (c) their likelihood of pursuing a career in psychiatry; and (d) factors that might discourage them from becoming a psychiatrist. This paper will report the findings relating to items (c) and (d).
The questionnaire was piloted electronically on 27 medical students who were pursuing an intercalated BSc Med Sci degree. All of these students responded and the questionnaire was modified in response to comments. Respondents reported that the questionnaire took about 10 min to complete.
Following questions designed to elicit views about psychiatrists and psychiatry, students were asked: ‘Do you think you will specialise in psychiatry?’ and were given response options of ‘Definitely’, ‘Probably’, ‘Possibly’, ‘Probably not’ and ‘Definitely not’.
Factors that might discourage students from pursuing a career in psychiatry were then presented. The seven factors selected derived from earlier studies of foundation doctors in Scotland. Reference Shah, Brown, Eagles, Brown and Eagles21 In these studies, 31 factors had been listed that may have influenced career choice and these 7 factors emerged as those rated more negatively than positively with regard to a potential career in psychiatry.
Students were asked: ‘Which of the following discourages you from choosing psychiatry as a career?’ The listed items were:
• standing of psychiatrists among the general public
• standing of psychiatrists among the medical profession
• comments by other specialists about psychiatry
• amount of paperwork/bureaucracy in psychiatry
• scientific basis of psychiatry
• a perceived lack of evidence base
• prognosis of patients in psychiatry.
The response options given were: ‘Not at all’, ‘A little’, or ‘A lot’.
With the exception of the intercalating BSc Med Sci students who had been involved in completing the pilot questionnaire, all medical students in first to fifth years at Aberdeen University were sent questionnaires electronically in February 2010, following prenotification about the survey. Reminders were sent after 2 and 7 days. Following the electronic survey, paper versions of the questionnaire were made available to non-respondents at lectures and clinical teaching sessions. All electronic and paper responses were anonymous. Ethical approval was obtained from Aberdeen University's College of Life and Sciences and Medicine Review Board.
From 918 students, 416 electronic and 54 paper responses were received. Of the total of 470 responses, 467 were completed adequately yielding a 50.9% useable response rate. Responses across the years varied from a high of 65% among first-year students to a low of 43% among second-year students. Female response rates at 56% exceeded those from male students at 44%.
Responses to the question: ‘Do you think you will specialise in psychiatry?’ are shown, by year group, in Fig. 1. Responses of ‘Probably’ and ‘Definitely’ are collapsed, as are those of ‘Probably not’ and ‘Definitely not’.
The percentage of students who definitely or probably intend to become a psychiatrist remains essentially level at between 4 and 7% across the five undergraduate years. Progressive proportions of students decide that psychiatry is not the career for them but by the final year, in addition to the 6% who deem it a probable or definite career choice, another 17% were still considering psychiatry as a possibility.
Table 1 shows the responses of all students to the questions about factors that may discourage them from choosing a career in psychiatry. More than half of students were put off by perceptions about the evidence base and the scientific basis of psychiatry, and the prognosis of psychiatric patients was the most discouraging perception.
|Not at all||A little||A lot|
|Standing of psychiatrists among the general public||70||28||2|
|Standing of psychiatrists among the medical profession||63||31||6|
|Comments by other specialists about psychiatry||69||26||5|
|Amount of paperwork/bureaucracy in psychiatry||52||37||11|
|Scientific basis of psychiatry||47||35||18|
|A perceived lack of evidence base||49||37||14|
|Prognosis of patients in psychiatry||38||42||20|
To establish changes that may occur across the 5 years of undergraduate training, responses were analysed by chi-squared tests for trend. Of the seven potentially discouraging factors, five showed no significant change, but decreasing proportions of students became discouraged by a perceived lack of evidence base (P > 0.001) and by the amount of paperwork/bureaucracy in psychiatry (P = 0.023).
This study had the merit of eliciting views from students across the undergraduate years and thus having the potential to show evolution of career intentions and perceptions of factors that might reduce enthusiasm for a career in psychiatry. The response rate, although reasonable for a survey of this type, was just over 50%. It is quite possible that non-respondents had less positive attitudes to psychiatry and would have been less likely to have entertained the specialty as a potential career choice; female response rates were higher than those from males, and we know that women generally tend to have more positive attitudes towards psychiatry and to a psychiatric career. Reference Wilson and Eagles22 Practical factors, such as the proximity of examinations for second-year medical students and the dispersal of final-year students to geographically distant placements, may well have adversely influenced response rates in our study. Although the questionnaire came from the first author with no stated departmental affiliation, respondents may have been influenced by perceiving that psychiatry was involved in conducting the study.
It would have been potentially instructive to have had comparative information on the development of career choice for other specialties. In the absence of such data it is difficult to know whether the increase in those who would probably or definitely not wish to pursue a career in psychiatry (from 56% in the first year to 77% in the final year) reflects a reduction in enthusiasm towards psychiatry or increasing crystallisation of other career options. In The Netherlands, Tijdink et al Reference Tijdink, Soethout, Koerselman and ten Cate23 noted a decrease in interest in a psychiatric career as medical students went through their training and felt this to be in keeping with an increasing focus on other particular specialty choices.
The proportion of students with a probable or definite intention of becoming a psychiatrist stayed fairly level across the undergraduate years. Although it seems more likely, from what we know about formation of specialty choice, that individual students fluctuate in their career intentions, it is possible that the same students start and finish their medical student years with a psychiatric career in mind. A longitudinal study would be required to clarify this possibility.
The focus of this paper is on factors that may influence medical students to become psychiatrists. However, the findings also raise issues about student selection and postgraduate recruitment, and these points will be covered briefly.
Medical student selection
In Maidment et al's study Reference Maidment, Livingston, Katona, Whitaker and Katona18 of sixth formers contemplating a career in medicine, only 25% deemed psychiatry to be a ‘not very attractive’ career option and 14% indicated that they would definitely not wish to become a psychiatrist. Comparison of these responses with those from our first-year students suggests that successful applicants to medical school may differ from unsuccessful applicants or that, less plausibly, students become rapidly less keen on a career in psychiatry after only a few months at medical school. Brockington & Mumford Reference Brockington and Mumford2 and Malhi et al Reference Malhi, Parker, Parker, Carr, Kirkby and Yellowlees6 have suggested that a focus on medical student selection processes is a very important component of enhancing recruitment into psychiatry.
Although it is worth re-emphasising that our figures may be inflated due to higher response rates from students more positively disposed towards psychiatry, 6 months before graduating 6% of final-year students considered psychiatry to be a definite or probable career choice and a further 17% deemed it to be a possibility that they might become a psychiatrist. Recruiting only a relatively small proportion of these ‘possibles’ would solve our current workforce problems.
Confirming earlier studies, Reference Brockington and Mumford2,Reference Eagles, Wilson, Murdoch and Brown7,Reference Cameron and Persad24,Reference Goldacre and Lambert25 Goldacre et al Reference Goldacre, Laxton and Lambert26 recently found that psychiatry has continued to recruit ‘late choosers’ among UK graduates of the 1990s. Exposure to psychiatry as a foundation doctor markedly increases enthusiasm for a career in the specialty Reference Shah, Brown, Eagles, Brown and Eagles21 and we should thus continue to advocate an increase in numbers of psychiatric foundation posts, especially within the earlier placements before applications for specialist training are made.
Influences on students’ career choices
Our findings confirm that the standing of psychiatry among the public and among medical colleagues detracts from the attractiveness of our specialty for students. Reference Malhi, Parker, Parker, Kirkby, Boyce and Yellowlees3,Reference Brown, Addie and Eagles8,Reference Baboolal and Hutchinson27,Reference Wigney and Parker28 These factors are, presumably, quite closely related to students’ exposure to negative comments (‘bad mouthing’) about psychiatry and psychiatrists; such comments are not confined to psychiatry but have been reported as exerting a negative effect on perceptions of a career in bad-mouthed specialties. Reference Hunt, Scott, Zhong and Goldstein29,Reference Kamien, Bassiri and Kamien30 However, only a small percentage of students endorsed the feeling that either the prestige of psychiatry or the prevalence of negative comments discouraged them ‘a lot’. Addressing these perceptions and behaviours is a complex issue and of clear importance beyond the confines of recruitment of psychiatrists.
The amount of paperwork and bureaucracy in psychiatry put off 37% of students ‘a little’ and 11% ‘a lot’. However, as students progressed through medical school, this factor became less discouraging probably as students appreciated that other specialties (notably general practice) may share this problem to a similar or greater extent.
Other studies have also found that perceptions of a lack of basis in evidence and/or science has a negative effect on students’ enthusiasm to pursue a psychiatric career. Reference Malhi, Parker, Parker, Kirkby, Boyce and Yellowlees3,Reference Malhi, Parker, Parker, Carr, Kirkby and Yellowlees6,Reference Balon, Franchini, Freeman, Hassenfeld, Keshavan and Yoder9,Reference Rajagopal, Rehill and Godfrey19,Reference Wigney and Parker28,Reference Robertson, Walter, Soh, Hunt, Cleary and Malhi31 More than half of our student sample was put off a career in psychiatry by these perceptions. It was encouraging that students became less discouraged by a perceived lack of evidence base; possibly this relates in part to fourth-year Aberdeen students’ participation in preparation and presentation of an evidence-based case study in psychiatry.
Students’ perceptions of the prognosis of patients in psychiatry was the most negatively rated factor in our study, discouraging 42% ‘a little’ and 20% ‘a lot’ from becoming a psychiatrist. Other studies support patient prognosis as a negative influence on attitudes and recruitment. Reference Balon, Franchini, Freeman, Hassenfeld, Keshavan and Yoder9,Reference Baboolal and Hutchinson27,Reference Robertson, Walter, Soh, Hunt, Cleary and Malhi31,Reference Holm-Petersen, Vinge, Hansen and Gyrd-Hansen32 In Denmark, Reference Holm-Petersen, Vinge, Hansen and Gyrd-Hansen32 students rated the degree to which they deemed treatment methods to be effective. Perceptions of the effectiveness of psychiatric treatment improved after 4-week psychiatric attachments but were still well below ratings for surgery, medicine and general practice. Perhaps not surprisingly, first-year medical students were found to rank the ability to help patients as their most important determinant of specialty choice, Reference Baboolal and Hutchinson27 emphasising how crucial perceptions of prognosis may be to recruitment.
Implications for recruiting medical students to psychiatry
Although this paper has focused on discouraging factors that we can seek to modify, clearly the positive aspects of a psychiatric career should be emphasised to students. The ‘big three’ attractive factors in choosing psychiatry are hours and conditions of work, doctors’ assessments of their own aptitudes and their experience of psychiatry as a student. Reference Goldacre, Turner, Fazel and Lambert33 From a recruitment perspective it is thus vital that we identify and encourage students with aptitude for psychiatry, emphasise the positives of a career in the specialty and do all we can to optimise their undergraduate experiences. Reference Eagles, Wilson, Murdoch and Brown7
With regard to prestige and bad-mouthing, perhaps anti-stigma campaigners have not yet focused sufficiently on students and other healthcare professionals. Reference Brown, Addie and Eagles8 Discouragement through a perceived lack of science and evidence base can be addressed by introducing more of the underlying science (including psychology and sociology as well as neuroscience) into psychiatric teaching at an early stage and by emphasising the firm evidence base underlying much of psychiatric practice. Concomitantly, we must ensure that the attractions of rewarding interactions with patients in a holistic person-based specialty Reference Malhi, Parker, Parker, Kirkby, Boyce and Yellowlees3 continue to be flagged up to students.
Negative perceptions about the prognosis of patients in psychiatry stood out as the most discouraging factor. It is difficult to address the issue of prognosis generically across psychiatric diagnoses, especially when the effectiveness of psychiatric interventions differs hugely between different disorders. Reference Andrews, Issakidis, Sanderson, Corry and Lapsley34 Although it is likely that the prognosis and the effectiveness of treatment for patients seen by psychiatrists is rather better than those seen in most areas of general medicine, this would contrast starkly with the views of medical students. Reference Holm-Petersen, Vinge, Hansen and Gyrd-Hansen32 The desirability of exposing students to patients with good prognoses was emphasised 30 years ago, Reference Eagle and Marcos35 and it may be helpful if psychiatric educators consciously introduce information about prognosis to teaching sessions.
This paper derives from the first author's thesis for her BSc Med Sci degree at Aberdeen University. We are grateful to Neil Scott for his statistical assistance and to John Lemon for his input into the electronic survey. We thank the study participants and Lana Hadden who did the secretarial work for this paper.