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Psychiatric training for the next generation

  • Clare Oakley (a1) (a2), Josie Jenkinson (a1) and Femi Oyebode (a3)
Summary

Recent concerns about the future of psychiatry have led to various calls for action. We argue that an overhaul of postgraduate training in psychiatry is the necessary first step to ensuring a strong future for the profession. Central to these improvements are reaffirming the ideals of psychiatric training, ensuring appropriate prominence of crucial knowledge and skills in the curriculum and providing tailored training placements with an emphasis on excellence. It is imperative that short-term service-provision need does not adversely have an impact on the training that is needed to ensure excellent patient care for the future. We urge the College to continue to work closely with psychiatric trainees to secure their future.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Clare Oakley (clare.oakley@kcl.ac.uk)
Footnotes
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This is one of a series of papers on recruitment in psychiatry. See also pp. 21–24 and pp. 30–32, this issue. Additional papers on this topic are due for publication in the February issue.

Declaration of interest

C.O. and J.J. are past Chairs of the Psychiatric Trainees' Committee of the Royal College of Psychiatrists but the views expressed are their own.

Footnotes
References
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11 Oyebode, F. Competence or excellence? Invited commentary on … Workplace-based assessments in Wessex and Wales. Psychiatr Bull 2009; 33: 478–9.
12 General Medical Council. Recognising and Approving Trainers: A Consultation. GMC, 2012.
13 Oakley, C, Malik, A. Psychiatric training in Europe. Psychiatrist 2010; 34: 447–50.
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15 Agarwal, S, Singh, Y, Palanisamy, V, Basker, R, van der Speck, R. Psychotherapy requirements as recommended by the College: awareness and achievement by senior house officers. Psychiatr Bull 2007; 31: 394–6.
16 Siddiquee, RA, Qaadir, AA. Psychotherapy competencies in trainees in South Wales. Psychiatr Bull 2007; 31: 398–9.
17 Psychiatric Trainees' Committee. Finding the Balance: The Psychiatric Training Value of Out of Hours Working. Royal College of Psychiatrists, 2008 (http://www.rcpsych.ac.uk/pdf/PTC%20The%20training%20value%20of%20OOH.pdf).
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20 Malik, A, White, O, Mitchell, J, Henderson, P, Oakley, C. New Ways of Working and psychiatric trainees. Psychiatr Bull 2008; 32: 230–2.
21 Craddock, N, Kerr, M, Thapar, A. What is the core expertise of the psychiatrist? Psychiatrist 2010; 34: 457–60.
22 Jauhar, S. Integrating research into the career of a psychiatrist in the past, present and future? Psychiatrist 2010; 34: 37.
23 Garralda, ME. Integrated academic training pathways and academic child and adolescent psychiatric training. Psychiatrist 2012; 36: 32–3.
24 Fogel, J. Research as part of the career of a psychiatrist entering clinical practice. Psychiatr Bull 2009; 33: 269–72.
25 Academy of Medical Royal Colleges and NHS Institute for Innovation and Improvement. Medical Leadership Competency Framework. Academy of Medical Royal Colleges and NHS Institute for Innovation and Improvement, no date (http://www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_framework_-_homepage.html).
26 Centre for Workforce Intelligence. Shaping the Medical Workforce: Starting the Debate on the Future Consultant Workforce. Centre for Workforce Intelligence, 2012 (http://www.cfwi.org.uk/publications/leaders-report-shape-of-the-medical-workforce).
27 Royal College of Psychiatrists. Recruitment Strategy 2011–2016. Royal College of Psychiatrists, 2012 (http://www.rcpsych.ac.uk/pdf/RecruitmentStrategy(RCPsych,2012).pdf).
28 Curtis-Barton, MT, Eagles, JM. Factors that discourage medical students from pursuing a career in psychiatry. Psychiatrist 2011; 35: 425–9.
29 Eagles, JM, Wilson, S, Murdoch, JM, Brown, T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull 2007; 31: 70–2.
30 Korszun, A, Dharmaindra, N, Koravangattu, V, Bhui, K. Teaching medical students and recruitment to psychiatry: attitudes of psychiatric clinicians, academics and trainees. Psychiatrist 2011; 35: 350–3.
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Psychiatric training for the next generation

  • Clare Oakley (a1) (a2), Josie Jenkinson (a1) and Femi Oyebode (a3)
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eLetters

Psychiatric training for the next generation: author's reply

Clare Oakley
25 February 2013

We are encouraged that our paper has sparked some debate of these important issues. We agree with Conn & Husain that conducting emergency assessments out-of-hours is a crucial component of training in psychiatry. We also support the Section of Neuropsychiatry's view that evaluation of the practical aspects of implementing a more integrated curriculum would be beneficial.

We understand the arguments put forward by Burza & Hilton about the value of old age psychiatry and their assertion that it has non-paritywith other specialties in our proposed scheme for postgraduate training inpsychiatry. It was not our active intention to reduce trainees' exposure to old age psychiatry but this was a product of the challenge of trying toaccommodate neurology, psychopharmacology and psychotherapy which currently are not routine placements. However, we intend our paper to stimulate discussion and would hope that this, and other perspectives, could lead to further shaping of a proposal for psychiatric training for the next generation.

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Conflict of interest: None declared

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A Meeting point for Neurology and Psychiatry?

Rory Conn, CT3 Trainee
12 February 2013

The article by Oakley et al. (2013) highlights an important training gap in the current curricula of both psychiatrists and neurologists. Amongother interesting considerations, the article proposes "in the first year of training, a 4-month placement in neurology becomes an integral part of core training... to consolidate clinical examination skills and provide experience in the interface between neurological and psychiatric disorders".

Historically, there is a tradition of cross-fertilisation between neurology and psychiatry, exemplified by the recent renaissance of the "bridge" disciplines, neuropsychiatry and behavioural neurology (Silver 2006; Agrawal et al. 2008; Arambepola et al. 2012). Standards of clinical practice and applied research have benefitted from specialists trained in the assessment and management of behavioural symptoms resulting from pathologies of the central nervous system. In some countries, including United States and Germany, the opportunity of exploiting these reciprocal benefits is already formalised with integrated curricula at postgraduate training level (Silver 2006).

In the United Kingdom, compared to their predecessors, psychiatry trainees have fewer opportunities to gain neurological and medical experience before specialization. It has become increasingly difficult to move between specialties and there is little incentive for trainees to attain MRCP qualification. Over the last few years, the evolving discipline of neuropsychiatry has made some initial steps to bridge this gap (Agrawal et al. 2008; Arambepola et al. 2012).

Based on these observations, the Section of Neuropsychiatry agrees with the direction of the proposal by Oakley et al. and encourages furtherdiscussion to translate valuable principles into practice. From the psychiatry trainee's perspective, achieving the College's core competencies (including working with patients with cognitive difficulties,neurodegenerative conditions) would be greatly facilitated by formal exposure to placements in neurology.The increasing necessity to optimise allocation and utilisation of health care resources would favour a revised curriculum, where the psychiatry trainee is provided with opportunities to learn about underlying neurological changes in traumatic brain injury, epilepsy or movement disorders. Trainees could also acquire the ability to diagnose conversion disorder based on physical signs (DSM-V).

Equally, care pathways which are currently far from efficient or cost-effective could be streamlined if the neurology trainee received exposureto the principles of conversion disorders and common behavioural symptoms and their management (Earl et al. 2011).

Finally, we feel that the same principles should apply to colleagues dealing with neurodevelopmental conditions, where formal training of childand adolescent psychiatrists would benefit from incorporating core elements of the paediatric neurologists' curriculum. In other Western countries (eg Australia, New Zealand) additional training in paediatrics and neurology is available through dual training programmes and additionalcertifications.

It is important that we examine psychiatric workforce development needs in the context of advances in neurosciences research and our developing knowledge of brain functions and brain disorders. The members of the Section of Neuropsychiatry express their wish that the proposal fora more integrated curriculum gains priority in the agenda of postgraduate educational committees, where the practical aspects of its implementation should be evaluated in the light of economical and logistical implications.

(499 words)

References:

Agrawal N, Fleminger S, Ring H, Deb S. Neuropsychiatry in the UK: planning the service provision for the 21st century. Psychiatr Bull 2008; 32: 303-306.

Arambepola NMA, Rickards H, Cavanna AE. The evolving discipline and services of neuropsychiatry in the United Kingdom. Acta Neuropsychiatr 2012; 24: 191-198.

Earl J, Pop O, Jefferies K, Agrawal N. Impact of neuropsychiatry screening in neurological in-patients: comparison with routine clinical practice. Acta Neuropsychiatr 2011; 23: 297-301.

Oakley C, Jenkinson J, Oyebode F. Psychiatric training for the next generation. Psychiatrist 2013; 37: 25-29.

Silver JM. Behavioral Neurology and Neuropsychiatry Is a Subspecialty. J Neuropsychiatry Clin Neurosci 2006; 18: 146-148.

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Conflict of interest: Submission made by Rory Conn and Andrea E. Cavanna, on behalf of the Executive Committee of the Royal College of Psychiatrists - Section of Neuropsychiatry, chaired by Rafey Faruqui

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What about Old Age Psychiatry?

Sabina Burza, Specialist Registrar, Central Northwest London NHS Foundation Trust
12 February 2013

We welcome the article by Oakley et al; creating a robust training programme more focused on developing medical expertise will go a long way to addressing the identity crisis currently ravaging psychiatry. However,we were concerned about the proposed structure of postgraduate training with regard to the dearth of old age psychiatry experience. Currently it is possible to undertake one, and in some cases two, six month old age placements at any point during core training. The proposed training reduces this significantly to one four month placement as a CT1. All other sub-specialities are represented by 6 month placements between CT2 and CT4. It is unclear why old age psychiatry has been excluded from this. Although old age experience at an early stage in training is important, this can only serve as a basic introduction to the specialty and will not allow for the development of expertise and excellence as emphasised in the Tooke report.

It seems perverse that the authors recommend increasing the total duration of training whilst reducing the time spent in old age psychiatry.To exclude old age psychiatry from CT2-CT4 placements suggests non-parity with other psychiatric specialities. We fear this may harm recruitment tothe field, as it becomes a distant memory by the time choices for specialization are made as a CT4. It neglects to tackle the situation of trainees who are undecided about old age psychiatry and would benefit fromfurther experience to aid their decision, or those who have, early on, settled on a career in old age psychiatry and wish to consolidate their experience in preparation for ST5. The authors raise the issue of 'functionalisation' of general adult psychiatry and the risk that traineesmay have very little exposure to in-patient treatment. That problem is resolved in the new proposals by two specific general adult placements each of 6 months. The new proposals do not equitably consider training issues raised by functionalisation in old age psychiatry.

Old age psychiatry is a multifaceted sub-speciality incorporating aspects of psychiatry, physical medicine and neurology. This marries wellwith the authors' suggestion of incorporating more of the latter in psychiatric training. Offering an older adult placement as a CT2-4 may help to maintain the momentum of focus on these skills, and enhance the expertise of all trainees.

1. Tooke J. Aspiring to Excellence. Findings and Final Recommendations of the Independent Inquiry into Modernising Medical Careers. MMC Inquiry, 2008 (http://mmcinquiry.org.uk/Final_8_Jan_08_MMC_all.pdf).

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Conflict of interest: None declared Authors: Dr Sabina Burza, Specialist Registrar, St Mary's Higher Training Scheme Harrow Older People and Healthy Ageing Service Bentley House Day Assessment Unit 15-21 Headstone Drive Harrow HA3 5QX Fax: 0208 4247773 Dr Claire Hilton, Consultant Psychiatrist Harrow Older People and Healthy Ageing Service Bentley House Day Assessment Unit 15-21 Headstone Drive Harrow HA3 5QX

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The Importance of Out-of-Hours Experience in Current and Future Psychiatric Training

Rory Conn, CT3 Trainee
16 January 2013

We welcome Oakley et al.'s timely contribution to the debate around the future of psychiatric training.

The issue of decreasing exposure to emergency assessments out-of-hours has been of concern to the Psychiatric Trainees Committee for several years (1). Originally a fear prompted by the introduction of Working Time Regulations, our unease is now focussed on the impact of widespread service reconfigurations; in some areas these are resulting in rotas whichdramatically restrict trainees' exposure to emergency learning experiences.

Are presentations qualitatively different out-of-Hours? Research in this regard is limited, but it is our unanimous opinion that outside of 9 to 5pm and particularly at night, patients tend to present with more complex and challenging problems, often involving dual diagnoses, drug and alcohol intoxication and higher rates of self harm and overdose. Services available are also more limited, making decisions about care more demanding.

We concede that out-of-hours rotas which involve trainees working off site, or not at all, may increase the trainee's time spent with patients in day hours, providing continuity of care and the opportunity to attend teaching and academic programmes. However, daytime work is often centred on service provision and routine tasks, rather than acquiring essential emergency competencies required to be a successful and accountable higher trainee and consultant.

Decreasing trainees' work out-of-hours may also serve to further devalue the image of psychiatry to other medical professionals - when seeking advice on a complex issue of risk, capacity or consent, for example, they expect to be able to speak to a medically qualified professional. As is well recognised, improving the image of psychiatry as a specialty is a key to reducing professional stigma and promoting recruitment.

In this same edition of The Psychiatrist, Tadros et al describe a revolutionary and highly successful 24 hours, 7 days a week method of working (2). We are of the opinion that the more services are designed with well-supported Core Trainees working at the coal face, particularly out-of-hours, the more training standards will improve and the more our specialty will be valued within the multidisciplinary environment. We alsobelieve that having medically trained professionals on the frontline makes for safer services.

The Psychiatric Trainees Committee (PTC) has established a working group to look into the provision ofout-of-hours services across the UK, with a particular aim of understanding how training might be impacted by reductions in out-of-hoursexperience. We will present the findings to the College and hope to work towards a shared understanding of the future of out-of-hours training.

Submitted by Dr Rory Conn (Out-Of-Hours Working Group Lead) and Muj Husain (PTC Chair) on behalf of the Psychiatric Trainees Committee.

References: 1. Finding the Balance: The Psychiatric Training Value of Out of Hours Working, Royal College of Psychiatrists 2008, www.rcpsych.ac.uk/pdf/PTC%20The%20training%20value%20of%20OOH.pdf 2. The Psychiatrist January 2013 37:4-10

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Conflict of interest: Rory Conn and Muj Husain are members of the current Psychiatric Trainees Committee

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