Sorting out the factors influencing medical students’ decisions about a career in psychiatry is clearly a difficult task. The importance of overcoming the negative perceptions of the specialty is a one vital aspect that needs to be addressed, ^{Reference Curtis-Barton and Eagles1} but a multitude of other issues need to be considered.

1. 1 Undergraduate medical training places great emphasis on medicine and surgery. Psychiatry, in our opinion, is not viewed as medicine because it basically forces students to relinquish those skills which take years to develop and which are so heavily emphasised in assessments, for example practical procedures and physical examination. These skills equate with being a good doctor, whereas the focus on psychosocial issues makes psychiatrists appear as less-than-real doctors.

2. 2 Some medical schools ignore psychiatry until the later years, making it an add-on specialty rather than a core part of our thinking about what medicine really is. Some do all their psychiatry in 6 or 8 weeks in the pre-final or final years. This is really like a drop in the ocean of the 5- to 6-year course.

3. 3 Some schools have incorporated the biopsychosocial model into every area in a so-called spiral learning model; this may change students’ attitudes.

4. 4 Liaison psychiatry, which is probably the psychiatric specialty with most overlaps and which interacts with other specialties, is noticeable by its absence in hospitals. The occasional patient with a psychiatric problem on the acute ward is often treated with little interest or enthusiasm by the medical or surgical teams. Referral is often made to psychiatry without any attempt to assess or manage the problem by the patient's team. This lack of enthusiasm definitely filters down to the students.

5. 5 Comparing attitudes to psychiatry in different medical schools before and after the first year of exposure, as well as the length of psychiatric attachment, might be useful. The latter is important because students’ exposure to specialties is often too brief. A 4-week attachment is long enough to observe a recovery from pneumonia, but not usually long enough for a depressive episode that has required hospital admission. Posting students in one psychiatric unit for the whole 6-8 weeks may be better than 1- or 2-week postings to four or five different specialist teams.

6. 6 Students are often discouraged to be hands-on on psychiatric wards. This leads to less engagement than in, say, an accident and emergency (A&E) post where they feel valued as a doctor-to-be.

7. 7 Approach to diagnosis is important; students are often dismayed by the overlap of symptoms across psychiatric disorders and probably even more by psychiatrists appearing to not adhere to specific criteria when making diagnoses. Often, students are told that a patient has a particular diagnosis without explaining why. Trainers could easily remedy this.

8. 8 Furthermore, psychiatrists are fairly vocal about psychiatric disorders being ultimately incurable. Even though many physical disorders such as diabetes, hypertension, asthma and psoriasis are chronic and incurable, the physicians speak more about what they can improve than what they cannot. Focus on improving patients’ quality of life and returning their ability to function is often not as obvious in psychiatry as it is in other specialties. Whereas other specialists gain a sense of achievement from tangible results and high-impact outcomes, psychiatrists deal with less clear-cut, multifactorial aetiology and less measurable outcomes.

9. 9 An issue that students may feel uncomfortable with is that psychiatrists sometimes enforce treatments on patients against their will. This contradicts the notion of the caring profession. Having seen how appreciative patients are of the work of the other specialists, a specialty where patients hate you for acting in their best interests can be very unattractive. The Mental Health Act and the role of mental health review tribunals are often not adequately explained to students, with tribunalsseeming to treat psychiatrists as villains who incarcerate vulnerable patients.

10. 10 Further, whereas most doctors are concerned about making patients better, psychiatrists seem over-preoccupied with the issue of risk rather than the idea of actually making patients better. It seems that they accept the blame when their attempts to treat patients fail, whereas no other specialty seems to hold such unscientific beliefs or take responsibility for natural outcomes of illnesses they treat. Similarly, in no other specialty are negative outcomes so widely publicised. The risk of adverse publicity discourages students from choosing psychiatry. It is more appealing to be viewed as a saver.

Overall, we might improve interest in and recruitment into psychiatry by posting medical students in psychiatry earlier in their training, offering longer postings, exposing them to specialties which interact most with medicine (e.g. old age psychiatry), giving them an opportunity to see patients on acute hospital wards and in crisis (e.g. A&E, crisis teams), and to follow-up patients into recovery.