How to run a psychiatry summer school {

Graduates in the UK are not choosing a career in psychiatry. This paper sets out to do three related things: review the factors that attract and deter medical students from a career in psychiatry, describe the provision of current summer schools and special programmes in psychiatry, and provide detail of how initiatives such as summer schools may be set up, run and evaluated locally to potentially address some of those issues identified in the first section.

What potential factors deter medical students from a career in psychiatry?
It has been shown that in Britain many medical students show an interest in psychiatry as a career while at medical school, but this fails to convert to the take up of a psychiatric training scheme on graduation. 4 Many studies have been carried out in Britain and elsewhere to determine the potential factors that deter students from psychiatry as a career. They cover several domains and include beliefs that the pace of the specialty is slow and there are few treatable conditions, 5 that psychiatry as a subject is conceptually weak and unscientific, [6][7][8][9][10][11] or boring, frustrating or depressing, 9 and lacks satisfactory outcomes, and 12 that clinical work with psychiatric patients is unappealing, 13,14 dangerous 12 or stressful. 8,9,12 Further studies have reported the consistently negative view of psychiatry by non-psychiatric doctors, [15][16][17] general practitioners and hospital nursing staff, 18 and the unfriendly medical school environment 14 as factors contributing to the 'large scale defections among students who were planning careers in psychiatry'. 19 Although these factors in themselves may be enough to put students off, other negative factors that have been reported include: low status among peers, family and society, 8 perception of a poorly funded service with lack of resources, low income when qualified, limited patient gratitude and job satisfaction 7 and, surprisingly, perceptions that working with mentally ill patients will make doctors themselves mentally ill. 20 In addition to all of the above, medical students are also subject to the hidden and informal curricula at medical school (e.g. role modelling experiences of students) which are biased against psychiatry as a career. 21 Box 1 summarises negative factors influencing students' perceptions about psychiatry found in the studies discussed here.
What potential factors attract medical students to a career in psychiatry?
Despite the negative press that psychiatry often receives, there are many factors that have been shown to attract medical students to the specialty (Box 2).
Many students consider psychiatry an interesting field, 22 with females having a more positive overall Summary Graduates in the UK are not choosing a career in psychiatry. This paper sets out to do three related things: review the factors that attract and deter medical students from a career in psychiatry, describe the provision of current summer schools and special programmes in psychiatry, and provide detail of how initiatives such as summer schools may be set up, run and evaluated locally to potentially address some of those issues identified in the first section. attitude. 23,24 Lifestyle factors have also shown to be important for some doctors choosing their career, 12 particularly for women: psychiatry has a good reputation for entry into flexible and less-than-full-time training 25 and training in psychiatry has been described as more compatible with family life. 26 In addition, capitalising on the benefits of family-friendly and flexible work practices is thought to enhance the attractiveness of the specialty. 27 In a survey of 655 Australian medical students, 12 those interested in a career in psychiatry rated several aspects as significantly more attractive, including: interesting subject, job satisfaction, lifestyle, bright and interesting future, intellectual challenge, association with colleagues, degree to which patients are helped, and financial reward. A thematic analysis of 33 student essays from another study 7 determined other important factors: good job prospects, variety of subspecialisation offered, working with a variety of approaches, opportunities for research, holistic approach, patient contact, chance to work in teams and with an underprivileged and stigmatised group of patients. Personal experience of others with mental health problems has also been noted to be significantly higher in studies of medical students who expressed an interest in psychiatry as a career, 9,28 as has experience of personal psychiatric therapy. 29 Gowans et al, 30 in a study of 2096 Canadian medical students showed that those interested in a career in psychiatry were more likely to have a family member or close friend practising as a psychiatrist and that they were more likely to be influenced by the prestige of psychiatry. Individuals with an educational background in the arts were also more likely to be attracted to psychiatry, 30,31 as were those reporting empathy for people with mental illness. 30 What can be done to help with the recruitment deficits among British graduates?
Among the variety of suggestions to increase recruitment as set out in the College's recruitment strategy, summer schools or special programmes aimed at interested medical students and foundation year doctors have been suggested as a way forward. There is a slowly growing body of evidence that initiatives such as summer schools could nurture some of the positively influencing factors and potentially mitigate some of the negative ones.
There are some dedicated summer schools and special programmes aimed at medical students with an interest in psychiatry already in existence: what can we learn from these? Factors related to patients: . working with underprivileged/stigmatised group . level of patient contact.
Other factors: . positive undergraduate educational experiences.

Current summer schools and special programmes in psychiatry
In 1970, Weintraub and colleagues began a 'Combined Accelerated Program in Psychiatry', 16 which still runs today at the University of Maryland, USA, taking on 12 first-year medical students each year (http://medschool.umaryland. edu/psychiatry/education.asp). A qualitative evaluation of recruits demonstrated that a number of important factors positively influenced the participants' attitudes to psychiatry: patient contact, association with senior staff members, small-group teaching, contact with other students interested in psychiatry, the chance to test one's aptitude for psychiatry, charismatic juniors, and contact with child and adolescent services. The most frequently mentioned aspects of these were early patient contact and association with senior staff. In Canada, Lofchy and colleagues have run a 5-day programme for first-and second-year medical students interested in psychiatry at the University of Toronto from 1994 to present day. 32 The results from an evaluation of the first 5 years of the programme showed that students valued enthusiastic doctors, a diverse programme, available and friendly staff, the meals and social events. The programme has continued on an annual basis and it has recently been reported that of the 222 students who attended it as undergraduates, 43% have taken up psychiatric training posts. 32 In light of the successes of the Canadian model, a similar programme was introduced in Western Australia in 2008, aiming to immerse the students in a 'world of psychiatry'. 33 The success of this programme is yet to be reported but there is sufficient evidence now to seriously consider if, and how, the UK might replicate similar initiatives.
Beginning in 2009, the Royal College of Psychiatrists has run a summer school for medical students who are interested in the possibility of a career in psychiatry. In collaboration with the Institute of Psychiatry and King's College London, the College delivers a programme of talks, demonstrations, tours of research laboratories and clinical facilities, opportunities to meet clinicians and researchers, and evening social events. Participants who do not live locally are offered free accommodation with a consultant and their family.
Several other medical school departments of psychiatry have followed suit and organised similar summer school programmes in Birmingham, Sheffield and others. The Birmingham summer school ran for the first time in 2011 and an evaluation demonstrated that the most valued aspects were the coverage of subspecialties, especially those that included a tour of the unit, and clinically led case discussions. The social events were highly rated and all participants indicated they would recommend the summer school to colleagues (J.G., personal data collection, 2011).
We will set out what to consider when setting up a similar summer school or special programme, based on our own experiences and the evidence base as far as it exists.

Who to invite?
There is debate on whether all medical students in any year of medical school should be invited (as the College does) or whether restrictions should be put in place and further possibilities should be created for invitations aimed at foundation year doctors.
The University of Maryland programme, which has been running by far the longest, specifically targets firstyear students only, although this is not strictly a singleevent summer school but a series of lectures, social events and tutorials throughout the time at medical school for a dedicated few. The Canadian and Western Australia programmes target first-and second-year medical students only. It can be argued that these programmes may be able to mitigate against the hidden and informal curricula that can detract students from psychiatry and, specifically, according to Weintraub, 'enthusiastic psychiatric faculty intimately involved with students over an extended period of time was the crucial factor neutralizing antipsychiatric socialisation experiences in medical school'. 19 The Birmingham summer school had only third-, fourth-and fifth-year students in attendance, on the basis that they are nearer to choosing their career and those in lower years would get further chances to apply. There is also the possibility that although students may show high levels of enthusiasm for psychiatry immediately after the summer school event, this may decline over time in a similar fashion to the longitudinal diminution in interest after the clinical psychiatry teaching attachment. 34,35 The decision about whether to invite foundation year doctors will need to be made and may depend on numbers that can be accommodated v. numbers of likely applicants. In addition, it will also need to be decided whether to restrict application to those who have not attended other similar events (as regional and national summer schools are now running, there are chances to attend more than one event). Similarly, overseas students may also apply and decisions about their attendance may need to be made.

Advertising the summer school
Who you are and who you want to invite will determine how you advertise.
For local medical school students, an advertisement can be put together and sent to all potential attendees via email, usually by contacting the medical school administrator responsible. The advertisement needs to give an outline of the programme, dates, method of application, when to return the application by and to whom. The local medical school psychiatric societies may help in promotion and advertising.
If targeting non-local medical students, consideration needs to be given to posting an advertisement on other medical school websites and the College has details for all student associates who could be contacted directly. Careers fairs may also be a useful way of advertising. For foundation trainees, consider a targeted email to all potential local foundation school doctors in either their first or at the beginning of their second year of foundation training. The timing needs to be considered, as ideally it needs to be before the cut-off for application to core psychiatry training programmes (mid to late December). The College has placed advertisements for its own summer school on its website and can advertise others. Deaneries may also place advertisements, especially for foundation year events. Posters and plasma screen advertising can also be considered with the permission of the relevant body. The College summer school YouTube video is an excellent advertisement for summer schools (www.youtube.com/ watch?v=MMWSrtVhk2k&feature=youtu.be).
If you are going to restrict attendees to a certain group, for example just fourth-and fifth-year medical students, it is important to state this clearly on any advertising (such as posters, plasma screens and website advertisements) that can be seen by other parties, otherwise you may have a large number of unsuitable applicants.

How to choose applicants
It is possible there may be many more applicants than can be accommodated and careful consideration must be given on how to rule applicants in or out. The method of application favoured by the College and Birmingham currently is to ask medical students to send an email of no more than 200 words stating why they would like to attend. The emails are received by the person running the programme or an administrator and it is suggested that they are independently scrutinised by two senior psychiatrists with predefined criteria, who then agree on the final attendees. In Birmingham we looked for level of commitment, enthusiasm as well as degree of uncertainty about future career. It needs to be emphasised that those who are clearly dedicated to a career in psychiatry already are not necessarily the people that need to be targeted. However, careful decisions need to be made in dealing with this group. You may decide to take them anyway so as not to alienate them or offer separate one-to-one sessions with the professor or suitable senior faculty member as well as taster sessions in any field they wished, and continued contact and support with subsequent job applications. This potential extra work needs to be considered and a dedicated faculty is a bonus.
The number of attendees you wish to or can accommodate depends on the programme you are offering. Pragmatically, if you are conducting tours of clinical sites the number that can be accommodated on each occasion needs to be carefully determined and agreed by those leading the sessions.

Student associates
It is worth telling all applicants, whether successful or not, about the Royal College of Psychiatrists' student associateships, a free membership scheme with a number of benefits and activities for students with an interest in psychiatry (www.rcpsych.ac.uk/training/studentassociates.aspx).

Timing
Thought needs to be given to maximising the attendance of your proposed participants. Lecture timetabling, curriculum organisation, electives and examinations need to be considered for medical students. The main consideration for foundation year candidates is to tie it in with the core psychiatry training application process. Consideration also needs to be given to the timetables of those involved who may be needed to support the programme, avoiding clashes with potentially busy times of the year, such as annual reviews of competence progression (ARCP, in June) and College CASC exams (January and September).

Costs and funding arrangements
The potential costs of a summer school programme can vary considerably. The principle cost may involve accommodation for those students who do not live locally. In Birmingham, we only advertised to local students so this was not an issue. The College asked local consultants to put students up for the length of the summer school and indeed this contact with senior faculty has an evidence base in attracting potential psychiatrists. 16 The College reports positive feedback from students who said that staying with consultants gave them good insight into the life of a consultant psychiatrist (M.T., personal communication, 2012).
Other costs are incurred by travel expenses, meals and refreshments, and evening social events, which may require outside catering and hiring of rooms. Further rooms may need to be hired for daytime events and selected remuneration and travel costs for any invited outside speakers, including service users and carers, may need to be budgeted for. If attendees do not have their own transport and visits to external sites are required, hiring and insurance of appropriate vehicles needs to be considered. Special travel claim forms may need to be drawn up for reimbursement from the funding agency. An approximate cost based on number of attendees needs to be worked out before funding is applied for.
Funding can be obtained from a variety of sources and combinations of funding streams can be put into place. Local trust boards have application procedures for charitable funding and in the case of the Birmingham summer school were willing to contribute. Other sources include deaneries, charitable organisations, the College and the private sector.

Setting up a programme of activities
Most summer schools will be set up by staff with access to clinical facilities and other interested clinicians who can lead on aspects of the proposed programme. It is suggested that a chair and organising committee comprising consultants, trainees and medical students be set up to solicit views and maximise local potential. Administrative support will be necessary. You may also want to prepare a mission statement, for example: 'The aim of the summer school is to encourage UK graduates to choose a career in psychiatry'.
The length of the programme needs to be considered. Currently, the College programme runs for 5 days, as do the Canadian and Western Australia programmes. In Birmingham, it ran over 3 consecutive days and had positive feedback that this was a reasonable length. Not all attendees may be able to attend all day and evening events if the programme is too long.
From an evidence-base perspective, the content can be set up to reflect and emphasise what we know about existing programmes as well as what has helped medical students enjoy their clinical psychiatric placements and what is documented as attracting students to psychiatry. For example, we know from evaluations of current summer school programmes and undergraduate teaching that students particularly and consistently value contact with patients, 22,36 encouraging consultants and senior doctors 4 as well as charismatic juniors 16 who are enthusiastic, friendly and approachable. 37 Meals and social events are highly valued, 37 probably because they facilitate informal contact with senior staff and other students or doctors interested in a career in psychiatry. The potential for support for other participants met on the programme may be very valuable given the evidence for the negative impact of the hidden curriculum at medical school. 21 This has been highlighted again more recently in a large survey of the opinions of psychiatrists, in which stigmatisation of psychiatric patients and professionals by the medical profession was the most dominant theme in putting students off a career. 38 A diverse programme with maximal subspecialty coverage has been demonstrated to be beneficial. 33 This was one of the most frequently mentioned positive features of the Birmingham and College programmes (J.G., evaluation of the 2011 Birmingham summer school and M.T., personal communication, 2010) and highlights the fact that many medical students are simply not aware of the existence of many psychiatric subspecialties which they may find challenging and exciting.
As well as clinical sessions, meals and invited speakers, other types of sessions can be organised such as quizzes, debates and mock trials. 'Speed-dating circuits' (students rotated every 5 mins to a different table where a consultant and trainee from a psychiatric specialty explained what their role involved) have been a popular feature of some summer schools, giving attendees the chance to encounter many different specialists over a short time span. Talks and interactive sessions can also be arranged on more diverse subjects such as history of psychiatry, psychiatry and films/ media/art, and personal accounts of mental illness. It may be possible to invite celebrity speakers and social events can also include trips to local attractions.
Students can be offered optional activities to choose from, for instance trips to clinical units or exposure to different specialties, which pragmatically can make the sessions more manageable with smaller groups. Examples of timetabled events are given in Box 3.

Evaluation of the programme
As an evaluation, a simple questionnaire can be handed out after the programme to gain insight on a variety of factors. For example, each of the components can be rated on a Likert-like scale and free-text answers can be sought to determine why attendees valued certain aspects of the programme above others. This will be helpful when planning what to include or modify for future events. Feedback can also be acquired on many of the non-clinical or administrative aspects of the programme, including the length, ease of access to facilities, catering, parking and transport arrangements.
Naturally, the key questions that need to be answered are whether the programme changes participants' attitudes to a career in psychiatry, whether the changes are sustained until a career choice is made and whether a significant proportion, over and above what would be expected, take up a career in psychiatry.
In addition to questionnaires, other ways of attaining feedback could be semi-structured interviews with groups or individual attendees, similar to a focus group. Care would need to be given as to who conducts the interviews to minimise any bias. Asking attendees to provide a reflective piece on their experience is an option; to prevent a low take-up, it could have desired headings, be completed on the last day or linked to the provision of an attendance certificate or prize. Audiovisual recording could also be used to provide feedback. The College has introduced the concept of an audiovisually recorded piece (e.g. recording the evening social events as they happened) to obtain information in real time about the programme and has been used to advertise the following year.

Other points to consider
Attendance certificates need to be drawn up and consideration for certificates for junior and senior staff as well as medical students that have contributed could be provided for inclusion in their portfolios. Administrative support is essential and best secured clearly and early given this is most likely a new activity for many, but possibly time consuming in the first instance. The running and evaluation of the summer school has many potential avenues for small research projects for interested health professionals and can be especially fruitful for interested senior trainees. There is also the possibility of research projects with a longitudinal perspective to determine whether there is an impact on recruitment over time as a result of the summer school. As the aim is to enhance recruitment to psychiatry, it would be useful to know whether, in fact, programmes such as this are having a beneficial effect. It must also be remembered that events of this sort have the potential to put people off psychiatry, thus evaluating the impact on attitudes to psychiatry as a career is a worthwhile exercise.
Interim evaluations have shown that the Birmingham and College cohorts have indicated an overall increase in desirability of pursuing psychiatry as a career (M.T., personal communication, 2010, and personal evaluation by J.G. in 2011), but it remains to be seen whether this effect is sustained. The Institute of Psychiatry intends to follow up its summer school attendees and attempt to evaluate how much influence the summer school has had on their subsequent career choice. All the Birmingham participants will be followed up in a similar manner as part of a longitudinal study. It has also been noted that students are more likely to get to know departmental staff and each other, which gives rise to the possibility of help with career choices at a personal level and development of communities of practice 39 for attendees.
The College has developed several arms of its recruitment strategy working through committees at all divisional levels. Psychiatry summer schools are just one of these arms. It is hoped that, if they are set up and run with the principles discussed here in mind, they may help to give British psychiatry some of the boost in recruitment levels it desperately needs.