The Scottish Division of the Royal College of Psychiatrists conducted a survey of members and fellows in 2003 on recruitment and retention within psychiatry. Responses relating to retirement intentions of consultants have been published previously (Reference Eagles, Addie and BrownEagles et al, 2005). Respondents were asked to give views about improving recruitment, and by far the most common suggestion was that this could be achieved by enhancing undergraduate teaching in psychiatry. This paper will discuss the ways in which undergraduate experiences may have an impact upon recruitment.

Recruitment issues

The distribution of consultant vacancies in psychiatry across the UK is variable (Reference StorerStorer, 2002), but overall 12% of consultant posts were unfilled at the time of the College's last national census (Royal College of Psychiatrists, 2002). Based on calculations in 1999, Brockington & Mumford (Reference Brockington and Mumford2002) suggested that 250–300 new consultants are required per annum in the UK for replacements and new posts. Factors which may affect this complex equation include the recent increase in numbers of medical students, the current debate about the level of unemployment among senior house officers, retention rates of junior psychiatrists and early consultant retirement. These issues are outside the scope of this paper. Our discussion will proceed on the basis that our recruitment problems are likely to persist and, even if they ease, that ‘ it should be seen as the responsibility of the whole profession to attract the brightest and best’ (Reference PiddPidd, 2003).

How do doctors choose their careers?

The processes which influence doctors in the choice of their careers are subtle and complex. McManus (Reference McManus1997) espouses the views that medical careers ‘can only really make proper sense to a chaos theorist’ and that ‘doctors mostly still find out about medical careers in the same way as adolescents used to find out about sex – through the mistaken, confused ideas of their peers in the playground’. In this context, the lack of career advice and support to medical students and newly graduated doctors has been criticised (Reference McManusMcManus, 1997; Reference Lambert and GoldacreLambert & Goldacre, 2002; Reference Mahoney, Katona and McParlandMahoney et al, 2004).

When young people are at the stage of considering a medical career, they deem many specialties (including psychiatry) to be very attractive options (Reference Maidment, Livingston and KatonaMaidment et al, 2003). Over the next 10–15 years, a complex set of ‘ push-and-pull’ factors influence career choice. Lifestyle factors seem to be of growing general importance (Reference Tolhurst and StewartTolhurst & Stewart, 2004). Against all the positive factors which may attract people into a particular specialty, it is necessary to balance repelling factors such as the impact of ‘bad-mouthing’ by specialists in other fields (Reference Hunt, Scott and ZhongHunt et al, 1996). It is helpful to bear in mind that attracting future psychiatrists takes place against this complex backdrop.

Medical student selection

Recruitment of good psychiatrists must depend to some degree on the selection of appropriate medical students. Petrides & McManus (Reference Petrides and McManus2004) found that doctors entering psychiatry and general practice were more likely to have an ‘ artistic’ approach to medicine, ‘seeing, interpreting and responding imaginatively to a range of medical, social, ethical and other problems’. In the USA, Sierles et al (Reference Sierles, Vergare and Hojat2004) found that before entry into medical school psychiatrists scored higher than other doctors in measures of verbal ability and general information. Brockington & Mumford (Reference Brockington and Mumford2002) noted that entry requirements for medical schools favour passes in science subjects, thus making it less likely that students will possess these qualities. However, the increasing proportion of female medical students may yield more graduates with a natural aptitude for psychiatry (Reference Wilson and EaglesWilson & Eagles, 2006).

Inclinations before entry to medical school were deemed to have a large influence on career choice in only 15% of the graduates surveyed by Goldacre et al (Reference Goldacre, Turner and Lambert2004), being significantly outweighed by factors during their undergraduate experience. Thus, although psychiatrists should encourage selection of appropriate students, with respect to recruitment into our specialty it should be accorded less attention than our interactions with medical undergraduates.

When do psychiatrists choose their specialty?

It is perhaps surprising that preferences before entry to medical school do not appear to greatly influence ultimate career choice (Reference Goldacre, Turner and LambertGoldacre et al, 2004). In Canada, Cameron & Persad (Reference Cameron and Persad1984) found that 14% of psychiatrists had decided to enter the specialty before starting medical school.

One year after graduation, 78% of male doctors and 72% of female doctors state that they have made a definite or probable choice of specialty (Reference Goldacre, Turner and LambertGoldacre et al, 2004), but in reality career intentions are likely to change in the early postgraduate years (Reference Goldacre and LambertGoldacre & Lambert, 2000). For psychiatry, it is encouraging that significantly more young doctors select than deselect a psychiatric career during the first three postgraduate years (Reference Goldacre and LambertGoldacre & Lambert, 2000; Reference Goldacre, Turner and FazelGoldacre et al, 2005). Cameron & Persad (Reference Cameron and Persad1984) reported that 58% of Canadian psychiatrists selected the specialty after graduation, having observed the frequency of psychosocial problems in other areas of medicine and the effectiveness of psychiatric therapies. It is hoped that the advent of Modernising Medical Careers, which will result in doctors making an earlier choice of speciality, does not reduce exposure to such experiences, with adverse effects on psychiatric recruitment.

Undergraduate influences on career choice

In their survey of sixth-formers contemplating a medical career, Maidment et al (Reference Maidment, Livingston and Katona2003) found that 49% of respondents considered psychiatry a ‘very attractive’ career choice and among students expressing a ‘definite intention’ psychiatry was the fourth most popular specialty. Something seems to change during the undergraduate years. Rajagopal et al (Reference Rajagopal, Rehill and Godfrey2004) found that only 3% of students at a London medical school rated psychiatry as a career they would wish to pursue. Exposure to clinical psychiatry tends to promote positive attitudes, so it seems that this negativity must derive from non-psychiatric sources.

Overemphasis on acute hospital-based medicine during undergraduate training acts as a powerful disincentive for recruitment into primary care (Reference Whitcomb and CohenWhitcomb & Cohen, 2004) and the same may apply for psychiatry. As Gray (Reference Gray1999) states: ‘ sometimes the whole ethos of a medical school can become dominated by high technology medicine with a specialist focus’. It does seem that the more exposure students have (to either community or hospital medicine), the keener they become upon careers in those areas (Reference Howe and IvesHowe & Ives, 2001). Early clinical experience, which is uncommon in psychiatry, may exert particular influences on career choice (Reference Littlewood, Ypinazar and MargolisLittlewood et al, 2005). Others feel that influences are less subtle, with direct negative effects on attitudes to psychiatry occurring during medical and surgical training (Reference Creed and GoldbergCreed & Goldberg, 1987). Psychiatrists have to work very hard at ‘ neutralizing antipsychiatric socialization experiences in medical school’ (Reference Weintraub, Balis and DonnerWeintraub et al, 1982). In our survey of Scottish psychiatrists, the low status of psychiatry among other medical professionals was considered to be the single factor which most adversely affected recruitment.

Turning to positive influences, Sierles & Taylor (Reference Sierles and Taylor1995) stated that ‘most authors believe the psychiatry clerkship is the most important medical school influence on recruitment’. Several studies have investigated changes in attitudes of students towards psychiatry and/or to a possible psychiatric career following psychiatric clinical attachments, and none has found that attitudes became more negative. Two found no significant change (Reference Galletly, Schrader and ChestermanGalletly et al, 1995; Reference Calvert, Sharpe and PowerCalvert et al, 1999), whereas more studies found that attitudes became increasingly positive (Reference Shelley and WebbShelley & Webb, 1986; Reference Sivakumar, Wilkinson and TooneSivakumar et al, 1986; Reference Creed and GoldbergCreed & Goldberg, 1987; Reference Alexander and EaglesAlexander & Eagles, 1990; Reference Singh, Baxter and StandenSingh et al, 1998; Reference McParland, Noble and LivingstonMcParland et al, 2003). Studies investigating specific aspects of clinical attachments which might give rise to attitudinal changes have been less common. Attitude changes were similar whether students were taught with problem-based learning or with a more traditional curriculum (Reference Singh, Baxter and StandenSingh et al, 1998; Reference McParland, Noble and LivingstonMcParland et al, 2004), although problem-based learning may give rise to better results in psychiatric examinations (Reference McParland, Noble and LivingstonMcParland et al, 2004). Positive attitudinal changes were found to be related to direct involvement in patient care, seeing patients improve with treatment and receiving encouragement from consultants (Reference McParland, Noble and LivingstonMcParland et al, 2003). Being kept busy and experiencing few boring meetings may also help to improve attitudes (Reference Sierles and TaylorSierles & Taylor, 1995). The perceived lack of a scientific foundation to psychiatric practice (Reference Malhi, Parker and ParkerMalhi et al, 2002) and concerns about over-identifying with patients (Reference Field and LennoxField & Lennox, 1996) can exert negative influences on the likelihood of pursuing a career in psychiatry.

Across the various medical specialties, several undergraduate factors influence career choice. In their survey of over 5000 new graduates, Goldacre et al (Reference Goldacre, Turner and Lambert2004) found that career choices were greatly influenced for 45% of graduates by experience of the chosen subject as a student and by a particular teacher or department for 27%. The importance of a good role model has been emphasised by others (Reference Watts, Marley and WorleyWatts et al, 1998; Reference Park, Minor and TaylorPark et al, 2005). Not surprisingly, doctors tend to pick subjects in which they feel that they have an aptitude as students, and this seems clearly to be the case for psychiatrists (Reference Goldacre, Turner and FazelGoldacre et al, 2005). Students seem to place increasing emphasis on the importance of lifestyle factors in their career selection (Tolhurst & Stuart, 2004) and ‘selling the merits of flexible, family-friendly working practices’ (Reference PiddPidd, 2003) within psychiatry should enhance the attractiveness of our specialty.

Conclusions

Many doctors make career choices in the early postgraduate years and perhaps the main goal of teachers should be to promote sufficiently positive attitudes among students for them to graduate still considering the possibility of becoming a psychiatrist. It is likely that recruitment of the best graduates may be enhanced by: encouraging early undergraduate exposure to psychiatry; identifying students with an aptitude for psychiatry and offering them encouragement and career advice; ensuring that students have busy clinical attachments in which they see patients who respond well to treatment; emphasising the growing evidence base underlying psychiatric practice; engaging proactively with students; and pointing out the potential lifestyle benefits of a psychiatric career.

Declaration of interest

None.