According to the myth, as punishment for his wicked behaviour Sisyphus was forced by Zeus to roll a large rock up a mountain side – however, before he reached the top of the mountain the rock would roll down again. Thus, Sisyphus was condemned to repeat for all eternity his ultimately futile actions. In 2009, the Royal College of Psychiatrists piloted a system for national recruitment to the first year of training (CT1) in England. It is therefore timely to review the continuing story concerning recruitment into postgraduate training in psychiatry.

The pattern of recruitment has shown consistent low levels from UK medical schools. Headlines such as ‘Psychiatry in crisis’ ^{Reference Oxtoby1} have merely confirmed the continuing difficulties in recruiting into psychiatry that date back at least 40 years. Numerous articles have been written on the subject over the past 25 years or so. Brockington & Mumford reviewed the literature and highlighted that the proportion of medical students who chose psychiatry as a career remained stable at about 3.6%. ^{Reference Brockington and Mumford2} They also suggested several ways to improve recruitment, including broadening the admission criteria to medical schools, more and better pre-registration experience of psychiatry, as well as background factors such as low status, and the stigma attached to mental illness and those who work in mental health services.

Continuing concerns led to an action plan being adopted in 2004, jointly by the Royal College of Psychiatrists and the Department of Health, to address the problems over recruitment and retention. Part of this plan was specifically aimed at increasing recruitment of medical graduates into psychiatry. This work plan was updated by the College Recruitment and Retention Working Group in 2006 with regard to Modernising Medical Careers (MMC) and New Ways of Working. This paper describes some of the trends in recruitment to psychiatry in one region (the West Midlands) and also nationally over the past 20 years in the light of the changes in both undergraduate and postgraduate training that have taken place over this period.

Recruitment in the West Midlands

The West Midlands was until 2008 the second largest postgraduate deanery in the UK. Despite a population of over 5.5 million (approximately 10% of the population of England), up until 2000, when the University of Warwick Medical School opened, it had only one medical school (the University of Birmingham), producing a total of 200 medical students a year. However, by 2007 the University of Birmingham was turning out 400 medical graduates annually and in addition, the Universities of Warwick (graduate entry only) and Keele were producing 300 graduates between them. Over the same period there have been major changes in the undergraduate medical curriculum throughout the UK. Within the University of Birmingham, for example, there was a decrease in undergraduate block teaching time for psychiatry from 10 weeks in the 1990s with a specialty-specific examination to the current level of 6 weeks teaching without the examination. Nevertheless, there have been positive changes too and from a position in the 1990s with no pre-registration experience in psychiatry available in the region, there are currently 28 foundation year 1 posts and 27 foundation year 2 posts regionally.

From 1986 to 1991, the all-Birmingham rotation in the West Midlands (the largest of the basic training schemes in the region at that time with 44 trainees) recruited 59% of its trainees from UK universities. ^{Reference Khan and Oyebode3} Extrapolating Mumford & Brockington's figures ^{Reference Brockington and Mumford2} and applying them to the regional medical school output would mean that if the rate of medical students choosing psychiatry remained constant at approximately 3.6%, it would be expected that 25 graduates would choose to do psychiatry each year. This is a sufficient number to fill the 25 CT1 training posts that were available in the West Midlands in August 2008. In reality, just seven UK graduates filled these posts. The number of ‘appointable’ candidates was 27. However, large numbers of these doctors were also applying to other medical specialties, especially general practice and core medical training (MMC Project Board, personal communication, 2008) as well as to other deaneries for psychiatry.

What is happening nationally?

The figures that the College has published ⁴ on individuals who take the College examinations provide a national indicator of the trends in recruitment and suggest that the findings obtained in the West Midlands are not due to local factors but apply nationally. It is difficult to make exact comparisons between the 2008 examination figures and those from previous years, as the recent radical changes that have taken place in both training and the examination structure may have led to some distortions in the figures. However, legitimate concern has been expressed that only 6% of the 655 candidates, equating to 39 candidates, who sat paper one in diet 2 in 2008 were UK graduates. ^{Reference Oxtoby1} In contrast, 970 of the 2604 candidates (37%) taking all parts of the College examinations in the whole of 1999 were UK graduates and of those taking the old part I Multiple Choice Question paper, 345 (30%, total n=1128) were UK graduates. ^{Reference Tyrer, Leung, Smalls and Katona5} Even if the 2008 figure is not exactly comparable, the magnitude of the decline in the number of UK medical graduates who opt for psychiatry is so dramatic that it cannot be ignored. What is particularly worrying is that the very low 2008 figures pertain to paper one and therefore relate to those recently recruited into psychiatry.

What are the challenges?

Recruitment into psychiatry remains problematic and recruitment from UK medical schools is particularly difficult, with the latter situation worsening. This means that the specialty has been more dependent than others on the work and contribution of international medical graduates. If it were not for the international graduates, psychiatric services would be in a stage of collapse. This is vitally important for two reasons. First, the outcome of Home Office immigration policy changes with their impact on the entry of international medical graduates into psychiatry could be disastrous for the specialty and for services. Second, a key principle underlying MMC is that the behaviours of doctors emerging from the UK ‘system’ (i.e. medical school graduation followed by foundation programme competence completion) will change. It is anticipated that doctors will assess their own abilities accurately, receive timely and high-quality career guidance, and make applications based on this coupled with contemporary data on competition ration for training posts and career prospects.

Questions need to be asked about why the described pattern, with regard to recruitment and performance, is continuing to occur and what, if anything, can be done about it?

There may be a number of reasons for the decline in the number of UK entrants to psychiatry. Unfortunately, despite extensive efforts on the part of the Royal College of Psychiatrists, stigma remains a major issue with regard to mental illness ^{Reference Crisp, Gelder, Goddard and Meltzer6} and the professional status of psychiatrists is poor compared with other medical professionals. ^{Reference Luty, Fekadu, O'Garga, Gallagher, Umoh and Mahadevappa7} It has been confirmed that the poor public image, low status and low morale contributed to doctors leaving psychiatry even once they had chosen it as their career path. ^{Reference Lambert, Turner, Fazel and Goldacre8}

Further, there has been a great change in the content and delivery of undergraduate curricula. There is a huge pressure on time within curricula as medical knowledge and specialties expand. In addition, there is greater emphasis on learning by way of interdisciplinary curriculum models, with the result that identified time within any single specialty has declined markedly. Eagles et al emphasised the importance of undergraduate exposure to psychiatry ^{Reference Eagles, Wilson, Murdoch and Brown9} and yet changes in the undergraduate curriculum have decreased this exposure greatly within the University of Birmingham. This must have had an impact on student perceptions of psychiatry and thus affect recruitment.

Historically, psychiatry has always appeared to compete with general practice for graduates. Recent Department of Health figures confirm that not only is there competition with general practice but also with core medical training (CMT). In 2008, over half of applicants to psychiatry also applied to general practice and 25% to CMT. The broader base afforded by CMT may appeal to some, but there may be other reasons that are driving doctors towards general practice from psychiatry. General practice may appear to medical graduates to allow a more flexible working environment, offer better remuneration and to be the focus of the government's plans for the future of the National Health Service (NHS). ^{Reference Darzi10}

Finally, it can be argued that the profession lacks clear direction, with a debate now taking place concerning the very role and raison d’être of the psychiatrist. This has focused on the dispute about the potential benefits and disadvantages of New Ways of Working for the profession. ^{Reference Vize, Humphries, Brandling and Mistral11,Reference Craddock, Antebi, Attenburrow, Bailey, Carson and Cowen12} All this may lead to the perception that psychiatry is a specialty that is aimless and unscientific, and possibly one that does not even require doctors, factors that are known to contribute to negative attitudes to psychiatry among medical students. ^{Reference Scott13,Reference Creed and Goldberg14}

What can the profession do?

It is clear that the problems in psychiatric recruitment in the UK are seen elsewhere, for example in the USA. ^{Reference Sierles and Taylor15} There are, however, a number of potential actions to be taken in the UK specifically.

The College is taking urgent steps to engage more closely with medical students. In early 2009, the Scoping Group on Undergraduate Education in Psychiatry reported on the substantial work they had undertaken. They developed a core curriculum for undergraduate psychiatry, explored ways of integrating psychiatric teaching throughout the medical school curriculum, investigated attitudes of medical students and general practitioners towards psychiatry and suggested standards for clinical teachers. A website was developed to promote psychiatry to medical students (www.rcpsych.ac.uk/medicalstudents). The work of the Scoping Group culminated in a national meeting on teaching and learning in undergraduate psychiatry that enabled sharing ideas and good practice.

The College has recognised the importance of ensuring that medical students are aware of the advantages of a career in psychiatry by taking steps to improve the quality of teaching to undergraduates and also to promote psychiatry more effectively among medical students. ^{Reference Oxtoby1} The recently introduced Student Associate grade of the College is free for any UK medical student or foundation doctor to join and provides useful information about a career in psychiatry and benefits including an annual undergraduate conference. Importantly, two Student Associates are co-opted onto the Psychiatric Trainees’ Committee, which allows sharing of information about training in psychiatry and gives the students a sense of truly being valued by the College. This collaboration has allowed the medical students to have increasing involvement in the evolving student section of the College website, a Student Associate e-newsletter and the developing network of local medical school psychiatry societies.

The College is rightly taking the lead in this initiative but it is the responsibility of every psychiatrist to engage positively with medical students both individually and with their medical schools, for example in recruitment into undergraduate programmes or participating in shared learning and assessment activities with other specialties. Medical students must be made to feel welcome during their placements in psychiatry and should be valued members of the clinical teams. This experience is crucial as encouragement received from consultants during their placement has a positive effect on students’ attitudes towards psychiatry. ^{Reference McParland, Noble, Livingston and McManus16} Trainees also have an important role to play in teaching and inspiring medical students, and indeed such teaching is an invaluable component of postgraduate training in psychiatry.

The College must continue to inform and lobby policy makers at the Home Office and the Department of Health with regard to overseas recruitment. Changes in immigration rules are likely to mean that in the future we will be unable to depend on doctors from outside the European Economic Area coming into the UK in the numbers they have in the past. Therefore, there is a need to closely consider the specific learning needs of international medical graduates in the continuing reform of training and training methods.

Finally, the profession must portray itself with a greater degree of unity and purpose to better shape the externally held perceptions of all those involved in a potential psychiatrist's career choice. This should be done in conjunction with service users and carers. At a time of great change, both within medical education and the NHS, medical graduates are more likely to be attracted to a profession with a clear idea of its roles and future. The challenge for those within the profession and the College is to be able to present a coherent vision of psychiatry that will attract prospective entrants into a profession that at its best offers one of the most stimulating, satisfying and worthwhile jobs available.

Declaration of interest

None.