In 2005, 2% of consultant posts in psychiatry in England were unfilled, with a further 15% of posts filled by locums (13th Annual Census of Psychiatric Staffing 2005, Royal College of Psychiatrists, http://www.rcpsych.ac.uk/training/census.aspx). In 2003 psychiatry accounted for 29% of all consultant vacancies in all specialties in England (364 out of 1264; Department of Health, 2003). The overall shortfall of doctors has been partially addressed by increasing the number of medical students and medical schools, but this does not address the more specific issue of shortage within the specialties (Reference Maidment, Livingston and KatonaMaidment et al, 2003). Goldacre et al (Reference Goldacre, Davidson and Lambert2004) found that only 4.3% of all respondents in the first year after their graduation signified that psychiatry was their first choice of long-term career, and there had been very little change between 1974 and 2000. Psychiatry was the least popular clinical specialty in a London medical school (Reference Rajagopal, Rehill and GodfreyRajagopal et al, 2004).
Several studies have considered factors that lead to the choice of psychiatry as a specialty. These have been carried out among potential psychiatrists in their premedical years (Reference Maidment, Livingston and KatonaMaidment et al, 2003), in medical school (Reference SchumacherSchumacher, 1964; Reference Wilkinson, Toone and GreerWilkinson et al, 1983; Reference Maidment, Livingston and KatonaMaidment et al, 2003), during pre-registration house jobs (Reference Creed and GoldbergCreed & Goldberg, 1987), and among senior house officers (SHOs; Reference Clarke-Smith and TranterClarke-Smith & Tranter, 2002; Reference Maidment, Livingston and KatonaMaidment et al, 2004). They have found that career plans change both during and after medical school. There has been a suggestion that the most specialty switching takes place in psychiatry (Reference Held and ZimetHeld & Zimet, 1975). In addition there is a high rate of ‘ attrition’ of SHOs in psychiatry, who do not progress to higher psychiatric training or to consultant grade posts (Reference CoxCox, 2000).
A study among consultant psychiatrists would indicate the reasons why people become psychiatrists, and might suggest rational interventions for increasing recruitment and retention. To date there have been few studies of psychiatrists at this stage of their career (Reference PrinsPrins, 1998). Our study of consultant psychiatrists aimed to explore their reasons for choosing the specialty and to help clarify the motivation of people who became psychiatrists, as opposed to those who intend to become psychiatrists and may change their mind.
Method
We designed a structured questionnaire using a Likert scale incorporating factors that had been suggested to relate to recruitment in psychiatry in a systematic review of current literature (Reference Wilkinson, Toone and GreerWilkinson et al, 1983; Reference PrinsPrins, 1998; Reference Baxter, Singh and DugganBaxter et al, 2001; Reference Galeazzi, Secchi and CurciGaleazzi et al, 2003; Reference Maidment, Livingston and KatonaMaidment et al, 2003; Reference McParland, Noble and LivingstonMcParland et al, 2003). We interviewed six consultant psychiatrists and conducted a focus group with SHOs in psychiatry to find out whether we had covered the entire range of reasons; this resulted in the addition of further questions. The questionnaire was then piloted among nine consultant psychiatrists in one of the mental health units within a London psychiatric training scheme, resulting in further changes in order to clarify some questions. The questionnaire was modified at the suggestion of the West London Mental Health Ethics Committee to include an open question, and was then sent to 87 consultant psychiatrists in substantive posts in a London psychiatric training scheme. Locum consultants were not included in the study as non-consultant grade doctors can cover these posts.
Analysis
Data were analysed using descriptive statistics and SPSS version 6 for Windows. The three most important reasons for choosing psychiatry were grouped together in order to have an adequate number of psychiatrists to compare results between groups. Associations between demographic variables and the reasons were assessed using the χ2 test. As this was an exploratory study where associations between variables were considered, the level of statistical significance was set at P=0.01 to avoid spurious results.
Results
Participants
Out of a total of 87 consultants surveyed, 72 (82.7%) returned completed questionnaires; 68% of participants were male (n=49); years of experience working as a psychiatrist ranged from 10 to 40 years (median 21) starting from SHO level or equivalent. The most common sub-specialty was general adult psychiatry (41.6%), followed by old age psychiatry (13.2%), child and adolescent psychiatry (9.7%), learning disability psychiatry and forensic psychiatry (6.9% each). There were 64 participants (90%) who worked full-time, 6 (8.38%) worked part-time and 2 who did not respond to the question. All but 1 of those who worked part-time were female; 51 participants (70.8%) described themselves as ‘clinicians only’, 12 (16.7%) were also medical managers, and 5 (7%) were clinicians and academics. Three of the respondents were psychotherapists, and of these, two were also medical managers; one participant was a clinician, academic and a medical manager.
Stage of choosing psychiatry
The majority of the participants (n=40, 55.5%) chose psychiatry as a specialty after leaving medical school; 30.5% (n=22) decided during medical school and 8.3% (n=6) decided on a career in psychiatry before medical school. Four participants did not respond to this question.
Country of primary medical qualification
There were 44 participants who qualified as doctors in the UK (61.1%) and 38.9% (n=28) who qualified overseas. Of the latter, 9 qualified in South Asia, 7 in Western Europe, 6 in Africa, 4 in Australia and New Zealand, and 2 in South America.
The ‘most important reasons’ for choosing psychiatry as a career
The ‘most important’ reasons for choosing psychiatry as a career are shown in Table 1; 36.1% (n=26) chose psychiatry as a career because of their empathy for those with a mental disorder; 25% (n=18) because of the interface of psychiatry with the neurosciences; 20.8% (n=15) because of the expectation of better working conditions in psychiatry; and 19.4% (n=14) because of medical school teaching.
‘Most important’ reasons for choosing psychiatry
| ‘ Most important’ factors influencing the choice of psychiatry | Participants n (%) |
|---|---|
| Psychiatric teaching received as a medical student | 14 (19.4) |
| Exposure to psychiatry as a house officer | 2 (2.8) |
| Psychiatrists met during medical training | 10 (13.9) |
| Members of family working in psychiatry | 2 (2.8) |
| Patients met during medical training (who were neither family or friends) | 8 (11.1) |
| Empathy for patients with a mental disorder | 26 (36.1) |
| Personal experience of mental disorder in yourself, family or friends | 4 (5.6) |
| Desire to understand yourself better | 5 (6.9) |
| Better working conditions expected in psychiatry (e.g. easier progress to consultant jobs and the working hours more compatible with a family) | 15 (20.8) |
| Possibility of treating mental disorder through alternative approaches (e.g. psychotherapy, an anthropological understanding) | 4 (5.6) |
| Interface of psychiatry with the social sciences (e.g. philosophy, anthropology or law) | 10 (13.9) |
| Interface of psychiatry with the neurosciences | 18 (25) |
| Disenchantment with other medical specialties | 7 (9.7) |
| Sense of fulfilment expected from seeing patients improve | 11 (15.3) |
Participants were asked to indicate other reasons which influenced their choice of psychiatry. Other reasons cited were a holistic approach (n=3), an interest in people (n=10), psychodynamic and psychological reasons (n=3), an interest in the subject (n=8), the importance of team work (n=4) and alternative treatment modalities.
There were no significant differences in the importance of medical school teaching as a factor in recruitment among those who decided on the specialty before, during or after medical school. There were no differences in importance of ‘better working conditions’ among male and female psychiatrists. There were no differences based on the country of primary qualifications.
Discussion
Most study participants decided on psychiatry after medical school and nearly a quarter had entered psychiatry after working in other specialties. This is similar to findings in Canada (Reference Cameron and PersadCameron & Persad, 1984) where 58.1% decided after medical school and 27% came from family practice. This study also confirms the extent to which overseas recruitment continues to mask the long-standing under-recruitment of British medical graduates into psychiatry. Recently, there has been an increase in the numbers of British medical graduates. It is premature to assume that the foundation year changes would lead to an increase in the number of medical graduates interested in psychiatry compared with other specialties.
It is likely that these results can be generalised to the whole of England as the study population was representative of the consultant population in the UK in terms of gender and choice of sub-specialty (Royal College of Psychiatrists, 2005). However, a greater proportion of our study population qualified overseas (Reference Goldacre, Davidson and LambertGoldacre et al, 2004).
Student attitudes to psychiatry improve after psychiatric attachments (Reference McParland, Noble and LivingstonMcParland et al, 2003). These improvements then decay after graduation, but it is uncertain whether they remain higher than pre-attachment levels (Reference Burra, Kalin and LeichnerBurra et al, 1982; Reference Sivakumar, Wilkinson and TooneSivakumar et al, 1986; Reference Baxter, Singh and DugganBaxter et al, 2001). The decay may be a result of the pull from other specialties, negative propaganda from other specialties (Reference Clarke-Smith and TranterClarke-Smith & Tranter, 2002) and narrow negative exposure to psychiatry after medical school. In the absence of exposure to psychiatry after medical school there is little to counteract these factors. After medical school, the narrow exposure of junior doctors to psychiatry may leave them with the impression that psychiatric patients are ‘difficult’ and ‘ incurable’.
Cameron & Persad (Reference Cameron and Persad1984) found that the rejection of other specialties, discovery of psychosocial problems in other specialties and discovering the effectiveness of psychiatric therapy influenced the choice of psychiatry. Participants in our study indicated that during their post-graduate years, they recognised that psychiatry offered the most holistic approach to patient care.
Reasons for choosing psychiatry
About a third of participants cited empathy for this patient group as an important reason for choosing psychiatry as a career. Although there was no difference on a humanitarian scale between medical students who showed a preference for psychiatry and those choosing other specialties (Reference EronEron, 1955), medical students who did not show a preference for psychiatry found people with mental illness anxiety-provoking and difficult; in contrast to psychiatrists’ who tend to have more positive attitudes (Reference Tucker and ReinhardtTucker & Reinhardt, 1968).
Direct involvement in patient care is an important factor in improving medical students’ attitudes to psychiatry during their attachment (Reference McParland, Noble and LivingstonMcParland et al, 2003). Longer attachments in psychiatry or more direct involvement in patient care might help to reduce the anxiety that medical students have of psychiatric patients and enable them to develop greater empathy for this group. Foundation year posts in psychiatry (Department of Health, 2002) may offer potential, but others have been more sceptical (Reference EaglesEagles, 2004). Increasing the numbers of general practitioner trainees might also improve recruitment in psychiatry.
The interface of psychiatry with the neurosciences was an important factor for 18 consultant psychiatrists in their choice of this specialty. This is consistent with previous work that suggested that the divorce of psychiatry from mainstream medicine had led to its relative unpopularity (Reference Thompson and SimsThompson & Sims, 1999). Galeazzi et al (Reference Galeazzi, Secchi and Curci2003) found that the perception of psychiatric care as evidence based and recognition of research opportunities in mental health were important factors that led to the choice of psychiatry as a career.
Working conditions experienced in psychiatry were an important factor for 15 of the participants. Following graduation, the choice of careers is influenced more by lifestyle than by specialty content (Reference Sierles and TaylorSierles & Taylor, 1995). In our study around half of those who felt that working conditions were an important factor cited better on-call working patterns or work-home balance as important. Without exposure to psychiatry after medical school, doctors are unlikely to recognise the better work-home balance that is possible with a career in psychiatry.
Medical school teaching of psychiatry was an important factor in choice of specialty (19.4%). This was equally true of those who had decided on the specialty after medical school as for those who had decided earlier. Liaison psychiatry, student psychotherapy schemes and community psychiatric postings have been shown to improve recruitment into psychiatry (Reference Clarke-Smith and TranterClarke-Smith & Tranter, 2002; Reference Yakeley, Shoenberg and HeadyYakeley et al, 2004). Enthusiastic teachers, encouragement from consultants, curability and direct patient involvement have all been cited as factors in medical school teaching which improved the attitudes of medical students (Reference McParland, Noble and LivingstonMcParland et al, 2003).
Limitations
This study was carried out among consultant psychiatrists in one London psychiatric training scheme. A retrospective survey of this kind may lead to systematic recall bias. Direct questioning will not always reveal motivations behind a career choice (Reference HalfordHalford, 2003). Furthermore, consultant psychiatrists are unlikely to admit that they made a mistake in their career choice.
Conclusions
This study confirms the importance of recruitment initiatives during medical school and in the early postgraduate years (Reference Goldacre, Davidson and LambertGoldacre et al, 2004). Attractive medical school teaching stresses the link between psychiatry and the basic sciences, and is evidence-based, it also offers greater direct involvement with patients. Recruitment may be particularly important after medical school to attract doctors or prevent them losing motivation.
Declaration of interest
None.
Acknowledgements
We thank Drs Bindhu Abraham, Rafey Farouqi, Simon Dein, Gillian Mezey and Serab Ozdural for their help.
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