Characteristics of included studies

Table 1 shows the characteristics of the 27 studies included in the review. The majority of studies (n = 24) were surveys and questionnaire-based studies. The other studies included one database study of doctors entering training posts and two retrospective cohort studies, which looked at which medical school psychiatrists had attended. These reported on medical students (n = 12), trainees (n = 10), medical students and trainees (n = 1), trainees and consultants (n = 1) and consultants (n = 3). One of these studies looked at data from postgraduate departments in different medical schools, and one study reported on the database of applicants to MMC (Modernising Medical Careers) for training posts.

Table 1

Study characteristics

Author/year	Population	Method/design	Total sample, n	M:F ratio, %/ response rate, %
Brook, 1976 Reference Brook19	Medical school of origin for psychiatrists	Retrospective cohort	531	No data provided
Brook, 1983 Reference Brook21	Medical school of origin for psychiatrists	Retrospective cohort	1229	No data provided
Levine et al, 1983 Reference Levine, Barzansky, Blumberg and Flaherty24	Medical students	Survey	30	No M:F data/100
Brook et al, 1986 Reference Brook, Ingleby and Wakeford20	Medical students	Survey	498	64:36/40
Calvert et al, 1999 Reference Calvert, Sharpe, Power and Lawrie33	Medical students	Survey	392	M:F, no significant difference/70
Mcparland et al, 2003 Reference McParland, Noble, Livingston and McManus30	Medical students	Cohort study – survey	379	54:46/84
Maidment et al, 2003 Reference Maidment, Livingston, Katona, McParland and Noble31	Medical students	Survey	837	33.6:66.4/99.6
Petrides & McManus, 2004 Reference Petrides and McManus23	Medical students	Cohort study – survey	8283	Only descriptive data provided in this paper
Rajagopal et al, 2004 Reference Rajagopal, Rehill and Godfrey35	Medical students	Survey	301	31.9:68.1/52
Curtis-Barton & Eagles, 2011 Reference Curtis-Barton and Eagles25	Medical students	Survey	467	44:64/51
Budd et al, 2011 Reference Budd, Kelley, Day, Variend and Dogra26	Medical students at 4 different medical schools	Survey	905	36:64/Not provided clearly reported range 50–85% depending on medical school
Archdall et al, 2013 Reference Archdall, Atapattu and Anderson34	Medical students	Survey	15	30:70/100
Halder et al, 2013 Reference Haider, Hadjidemetriou, Pearson, Farooq, Lydall and Malik28	Medical students – 18 UK medical schools	Survey	484	34:66/None
Farooq et al, 2014 Reference Farooq, Lydall, Malik, Ndetei and Bhugra27	Medical students (only UK data used)	Survey	291	Males 37:63/16
Maidment et al, 2004 Reference Maidment, Livingston, Katona, McParland and Noble31	Trainee doctors	Survey	234	52.1:47.9/67.4
Goldacre et al, 2005 Reference Goldacre, Turner, Fazel and Lambert14	Trainee doctors (graduates from 1974 to 2000, UK medical schools)	Survey	21 845 year 1 17 741 year 3	Year 1 55:45/75 Year 3 56:44/74
Lambert et al, 2006 Reference Lambert, Turner, Fazel and Goldacre15	Trainee doctors	Survey	572	No M:F data/74
Fazel et al, 2009 Reference Fazel and Ebmeier13	Trainee doctors (all applicants to MMC for training posts)	Database analysis	31 434	No M:F data
Barras & Harris, 2012 Reference Barras and Harris38	Trainee doctors	Survey	359	52.2:47.8/16.1
Goldacre et al, 2012 Reference Goldacre, Goldacre and Lambert16	Trainee doctors who had qualified in 2002, 2005, 2008	Survey	9155	37:63/56
Goldacre et al, 2013 Reference Goldacre, Fazel, Smith and Lambert17	Trainee doctors who qualified between 1974 and 2009	Survey	33 974	Year 1 49:51/65.9 Year 3 51:49/68.6 Year 5 52:48/69.5
Svirko et al, 2013 Reference Svirko, Goldacre and Lambert18	Trainee doctors who qualified 2005, 2008, 2009	Survey	9348	46.9:55.8/52.2
Collier & Moreton, 2013 Reference Collier and Moreton22	Hospital postgraduate departments of 19 medical schools	Survey	19 medical schools	No M:F data/70
Woolf et al, 2015 Reference Woolf, Elton and Newport37	Medical students and trainee doctors	Cohort study – survey	105	34:66/50
Korszun et al, 2011 Reference Korszun, Dharmaindra, Koravangattu and Bhui36	Trainee doctors, academics, trust clinicians	Survey	309	61.5:38.5/None
Dein et al, 2007 Reference Dein, Livingston and Bench39	Consultants	Survey	72	68:32/82.7
Denman et al, 2016 Reference Denman, Oyebode and Greening32	Consultants and trainees	Survey	Consultants: 47 Trainees: 51	55:45/41.7 (consultants 42%, trainees 41%)

M, male; F, female; MMC, Modernising Medical Careers.

a. Data not used from this paper just broad findings in review.

In survey-based studies response rates varied from 16% to 100%. Mean response rate from the papers which had figures available (n = 20) was 63.3%. The population in all studies comprised of 1879 psychiatrists, 6733 students and 220 746 trainees. One database study ^{Reference Fazel and Ebmeier13} looked at 31 434 trainee doctors, and studies by Goldacre et al were aimed at all doctors in training, accounting for large numbers of respondents in the trainee subcategory. ^{Reference Goldacre, Turner, Fazel and Lambert14–Reference Svirko, Goldacre and Lambert18}

The influence of the medical school and teaching practices

Most of the research addressing the influence of the medical school and teaching practices on selecting psychiatry as a career was carried out in the 1970's and 1980's. Two studies by Brook et al ^{Reference Brook19,Reference Brook, Ingleby and Wakeford20} looked at the medical school of origin for 531 psychiatrists between 1961 and 1970 and reported no significant relationship between schools that had a professional unit or specific teaching programme and students pursuing psychiatry in the long term. However, it was noted that those schools that produced fewer psychiatrists tended to have either a recently established professional unit or none. ^{Reference Brook19}

No clear pattern emerged in terms of the type of teaching offered at each university and the impact this had on choice of psychiatry as a career in the long term. ^{Reference Brook19} All four Scottish schools, and Cambridge and Oxford were noted to be higher in terms of producing psychiatrists, attributed possibly to the well-established professional units such as the Maudsley and Bethlem Royal hospitals. ^{Reference Brook19} The personality, charisma and enthusiasm of teachers were associated with an increase in the uptake of psychiatry in the long term. ^{Reference Brook19,Reference Brook21}

Brook et al ^{Reference Brook21} found that the effectiveness of teaching rather that the amount of teaching had an effect on student attitudes and recruitment into psychiatry The attitude of non-psychiatric teachers appeared to be influential with doctors experiencing negative attitudes of other doctors towards psychiatry. ^{Reference Brook21} The two hospitals which ranked top in terms of producing psychiatrists had changed their teaching model. One stressed the importance of psychiatry as being part of general medicine, emphasising the effectiveness of physical therapy, whereas the other placed emphasis on liaison psychiatry and psychotherapy. ^{Reference Brook21}

More recent work by Collier et al ^{Reference Collier and Moreton22} looked into the teaching time allocated for psychiatry in foundation programmes across the country. They found that only 2.3% of teaching was dedicated to psychiatry compared with 44.1% to medical and surgical topics. ^{Reference Collier and Moreton22} Exposure to psychiatry remained limited with 4 out of 17 hospitals in the survey not having any teaching on psychiatry for medical students. ^{Reference Collier and Moreton22} Doctors generally led a higher proportion of medicine and surgery teaching sessions (63%) compared with psychiatry (48%). ^{Reference Collier and Moreton22}

Medical students' views of psychiatry and factors affecting career choice

Twelve studies examined the factors affecting medical students' career choice and one study looked at both medical students and trainees. Petrides et al ^{Reference Petrides and McManus23} studied the theoretical understanding of how different medical specialties are perceived and how choices are made. Psychiatrists were found to have a more artistic approach to medicine, seeing interpreting and responding imaginatively to a range of medical, social, ethical and other problems. This is in keeping with early work by Levine et al ^{Reference Levine, Barzansky, Blumberg and Flaherty24} who also found that there was a group of students who were ‘psychologically minded’ and they could be identified and encouraged to make psychiatry as career choice.

Budd et al ^{Reference Budd, Kelley, Day, Variend and Dogra26} found that job satisfaction (98%, n = 128) and family-friendly status of psychiatry (79%, n = 103) were important for students who rated psychiatry as one of their top three choices. ^{Reference Budd, Kelley, Day, Variend and Dogra26} The academic status was significantly less important (48%) for students who placed psychiatry as their top three specialty schools v. 63% for those who did not place psychiatry in their top three choice. ^{Reference Budd, Kelley, Day, Variend and Dogra26}

Choice of psychiatry as a career among medical and sixth form students

The number of students choosing psychiatry has remained fairly stable at around 4–7%. ^{Reference Curtis-Barton and Eagles25–Reference Farooq, Lydall, Malik, Ndetei and Bhugra27} Three per cent of students from six medical schools placed psychiatry as their first choice, with 18% seriously considering it. ^{Reference Brook, Ingleby and Wakeford20} Halder et al ^{Reference Haider, Hadjidemetriou, Pearson, Farooq, Lydall and Malik28} found similar results in 18 medical schools; 16% chose psychiatry as a future career on entering medical school but by the final year only 3% had decided to pursue a career in the subject. These results were replicated by Farooq et al ^{Reference Farooq, Lydall, Malik, Ndetei and Bhugra27} In a survey of sixth form students, Maidment et al ^{Reference Maidment, Livingston, Katona, Whitaker and Katona29} reported that 60.9% (n = 363) indicated that it would be very likely or they would definitely want to pursue psychiatry as a career. In terms of overall intentions to pursue a career in a specialty, the ratings for psychiatry was similar to general medicine at 12.4% (n = 72) v. 12.2% (n = 69) respectively. ^{Reference Maidment, Livingston, Katona, Whitaker and Katona29}

Effect of undergraduate attachment and education on choosing psychiatry as a career

Positive attitudes towards psychiatry and the influence by a teacher during the attachment correlated with an intention to purse psychiatry as a career in the long term. ^{Reference Maidment, Livingston, Katona, Whitaker and Katona29–Reference Maidment, Livingston, Katona, McParland and Noble31} Three studies highlighted the importance of psychiatric attachment. Student attitudes improved as the attachment progressed. ^{Reference Budd, Kelley, Day, Variend and Dogra26,Reference McParland, Noble, Livingston and McManus30,Reference Maidment, Livingston, Katona, McParland and Noble31} Maidment et al ^{Reference Maidment, Livingston, Katona, Whitaker and Katona29} found 1.4% of fourth-year medical students expressed a definite intention to pursue which rose to 4.7% after their attachment. ^{Reference Maidment, Livingston, Katona, Whitaker and Katona29} McParland et al ^{Reference McParland, Noble, Livingston and McManus30} reported that 19% (n = 58/309) of students were very attracted to psychiatry or had a definite intention to pursue psychiatry at the start of the placement, which increased to 27% (n = 101/373) of students at the end of the attachment. The importance of the undergraduate experience was highlighted by a recent study showing 50% of consultants and 37% of trainees surveyed decided on a career in psychiatry while still at medical school. ^{Reference Denman, Oyebode and Greening32}

Calvert et al ^{Reference Calvert, Sharpe, Power and Lawrie33} looked into the attitudes of medical students towards psychiatry and psychiatric patients at year 1, 3 and 5 in medical school. First-year medical students were more likely to have stereotypical views compared with third- and fifth-year students, and were more likely to agree with statements such as ‘Psychiatry deals with imaginary illness’ (mean 1.4, s.d. = 0.9, P < 0.5). ^{Reference Calvert, Sharpe, Power and Lawrie33} Fifth-year students (mean 3.2, s.d. = 1.4) showed lower agreement than third-year medical students (mean 3.6, s.d. = 1.2, P < 0.5) with the statement ‘Psychiatry is as a challenging career’. ^{Reference Calvert, Sharpe, Power and Lawrie33} As they progressed through medical school, students recognised that mental illness has serious morbidity and that people do recover from mental illness, ^{Reference Calvert, Sharpe, Power and Lawrie33} showing that attitudes towards psychiatric patients improved with greater clinical experience but possibly became more negative towards psychiatry as a career.

Other factors that appeared to affect students positively included enrichment activities, i.e. activities beyond standard teaching and clinical placements led to a significantly increased interest in psychiatry. ^{Reference Haider, Hadjidemetriou, Pearson, Farooq, Lydall and Malik28} These included research experience in psychiatry (13% v. 4% in those not interested in psychiatry, P = 0.001), university psychiatry clubs (38% v. 11%, P < 0.001), psychiatry electives (14% v. 1%, P < 0.001) and psychiatry special study modules (38% v. 16%, P < 0.001). ^{Reference Haider, Hadjidemetriou, Pearson, Farooq, Lydall and Malik28}

McParland et al ^{Reference McParland, Noble, Livingston and McManus30} identified factors which increased interest in psychiatry, including: influence or encouragement by someone during the attachment (74%, n = 282), particularly the influence by consultants (43%, n = 163), exposure to interesting and stimulating ideas (29%, n = 110), liking someone's approach (27%, n = 103), feeling someone believed in their ability (11%, n = 41) and having formed close working relationships (9%, n = 33). ^{Reference McParland, Noble, Livingston and McManus30} Other factors that had a significant impact were: receiving encouragement from the consultants (n = 374, P < 0.001, r = 0.26), seeing patients respond to treatment (n = 374, P < 0.001, r = 0.20) and having a direct role in the involvement of patient care (n = 374, P < 0.001, r = 0.26). ^{Reference McParland, Noble, Livingston and McManus30}

Factors which did not affect career choice of medical students

Seeing patients in different settings or different phases of the illness had no effect on career choice of medical students when deciding their career intentions. ^{Reference Haider, Hadjidemetriou, Pearson, Farooq, Lydall and Malik28} Interestingly, one study found that the earning potential and status of psychiatry had no effect on selecting psychiatry as a career choice. ^{Reference Budd, Kelley, Day, Variend and Dogra26} Other factors related to teaching such as quality of rating of small group teaching and lectures, ^{Reference Haider, Hadjidemetriou, Pearson, Farooq, Lydall and Malik28} the curriculum type used ^{Reference McParland, Noble, Livingston and McManus30,Reference Maidment, Livingston, Katona, McParland and Noble31} and performance at viva examinations and multiple choice questions also had no effect on the career choice. ^{Reference Maidment, Livingston, Katona, McParland and Noble31}

Factors discouraging medical students to choose psychiatry as a career

Curtis-Barton et al ^{Reference Curtis-Barton and Eagles25} in their survey (n = 467) found that the factors discouraging students to pursue a career in psychiatry included: prognosis of patients (62%), perception that there is a lack of evidence in diagnosis (51%), lack of scientific basis (53%) and the amount of bureaucracy and paperwork in the specialty (48%). Other discouraging factors included the stigma towards psychiatry (30%), the standing of the profession among medical colleagues (31%) and comments by other specialists (26%). ^{Reference Curtis-Barton and Eagles25,Reference Archdall, Atapattu and Anderson34} Psychiatry scored the lowest among the specialties as a career choice. Students described psychiatry as boring, unscientific, depressing, stressful, frustrating and ‘not enjoying the rotation’. ^{Reference Rajagopal, Rehill and Godfrey35}

Many students experienced psychiatry as being different to other specialties. For some this was a reason not to pursue psychiatry as a career but for others it was a positive aspect of the specialty Students felt ward rounds focused on ‘social issues’ rather than medical conditions. Some found it an ‘emotional burden’ and others felt that psychiatry could not ‘fix’ people and no one is being cured. ^{Reference Archdall, Atapattu and Anderson34}

A survey by Korszun et al ^{Reference Korszun, Dharmaindra, Koravangattu and Bhui36} examined the views of trainee, academics and clinicians on students not taking up psychiatry. The following factors were identified as deterring the students from psychiatry: negative attitudes towards psychiatrists from other doctors and health professionals (57%), stigmatisation of psychiatry (40%), stigma associated with mental health disorders (39%), poor teaching and role modelling from psychiatrists (37%), psychiatry not seen as medical or scientific enough (26%) and poor morale among psychiatrists (26%). ^{Reference Korszun, Dharmaindra, Koravangattu and Bhui36}

Factors affecting trainees' and consultants' choice of psychiatry

Fazel et al ^{Reference Fazel and Ebmeier13} found that psychiatry was the sixth most popular specialty out of ten specialty groups for trainees applying for training places. A higher proportion of female graduates were shown to choose psychiatry between 1974 (32%) and 1999 (59%). ^{Reference Fazel and Ebmeier13} However, a more recent survey showed a slight decline in the number of women choosing psychiatry over the last decade, 4.9% (1999) v. 4.6 % (2009). ^{Reference Goldacre, Fazel, Smith and Lambert17}

Goldacre et al ^{Reference Goldacre, Turner, Fazel and Lambert14} examined career choices for medical students over the past 40 years. The number of doctors choosing psychiatry as a career has hardly changed and remains around 4–5%, which is similar to figures from 1975. ^{Reference Goldacre, Turner, Fazel and Lambert14} It was noted that students who went on to work in psychiatry 10 years after graduation, 52% (224 out of 428) had chosen psychiatry in the first year after graduation and 71% (308 out of 434) had chosen it in year 3. ^{Reference Goldacre, Turner, Fazel and Lambert14}

In common with the factors attracting students towards psychiatry, numerous studies identified factors that appear to attract trainees towards psychiatry The major attractions for choosing psychiatry are listed in Box 1. Denman et al ^{Reference Denman, Oyebode and Greening32} found that the most common factor influencing core trainees' (60%) and consultants' (70%) decisions to specialise in psychiatry was emphasis on the patient as a whole. ^{Reference Denman, Oyebode and Greening32} Trainees highlighted that mental health was an area of need (53%) and empathy and concerns for people with mental illness (53%) were important reasons for choosing psychiatry. ^{Reference Denman, Oyebode and Greening32}

Barriers associated with not choosing psychiatry as a long-term career choice for trainees

Barras & Harris ^{Reference Barras and Harris38} explored trainee's experiences (n = 359) within psychiatry. Trainee attitudes were grouped into different categories. The attitudes towards psychiatry (12.6%), professional role (12%) and day-to-day working (11.3%) were identified as the main negative factors. Trainees raised concerns with the training programmes in psychiatry, such as problems with the rota and not having enough time with patients. ^{Reference Barras and Harris38} Many trainees felt frustrated with the Annual Review of Competence Progression (ARCP) process and workplace-based assessments, as well as the duplication of paperwork being a constant frustration. ^{Reference Barras and Harris38}

The studies identified a number of barriers against choosing psychiatry as a career (Box 2).

Trainees felt improvements were needed in terms of training opportunities and felt this could be enhanced by providing a variety of jobs, increasing research opportunities and increasing medical aspects of training. ^{Reference Barras and Harris38}

Work looking into consultant psychiatrists' views into why they chose psychiatry was limited to two papers. ^{Reference Denman, Oyebode and Greening32,Reference Dein, Livingston and Bench39} Dein et al ^{Reference Dein, Livingston and Bench39} found that the majority of consultants (46%) chose psychiatry as a career soon after leaving medical school, and a recent study surveying consultants in the West Midlands found that 50% had made their choice by graduation from medical school. ^{Reference Denman, Oyebode and Greening32} The main reasons cited by consultants for choosing psychiatry as a career included: empathy for those with a mental disorder (36.1%), interface with neuroscience (25%), expectation of better working conditions in psychiatry (20%) and influence of teaching at medical school (19.4%). ^{Reference Dein, Livingston and Bench39} Denman et al ^{Reference Denman, Oyebode and Greening32} highlighted several ‘very important’ reasons for consultants choosing psychiatry including: career in psychiatry would be intellectually challenging (60%), sense of fulfilment expected from seeing patients improve (47%) and enjoyment of problem-solving (47%). Lifestyle factors such as salary, better working conditions and quality of life were shown to be more important reasons for choosing psychiatry for trainees compared with consultants. ^{Reference Denman, Oyebode and Greening32}