Recruitment , undergraduate education and the possibleimpact of Tomorrow ' s Doctors

Career choice Before discussing the possible impact of changes in the undergraduate curriculum in the UK on recruitment into psychiatry it is worth consider ing the evidence that undergraduate teaching influences career choice. Students at different medical schools in the UK have markedly different rates of choosing psychiatry as a career. Parkhouse & McLaughlin (1976) surveyed all doctors graduating in 1974 and asked them about career choice. General practice (32.9%) and medicine (22.5%) were the first two choices with psychiatry coming in sixth at 3.7%. However, the percen tage choosing psychiatry as first choice varied from 8.1% at Dundee to none at Charing Cross, St Bartholomew's and St Thomas'. Ellin et al


Career choice
Before discussing the possible impact of changes in the undergraduate curriculum in the UK on recruitment into psychiatry it is worth consider ing the evidence that undergraduate teaching influences career choice.
Students at different medical schools in the UK have markedly different rates of choosing psychiatry as a career.Parkhouse & McLaughlin (1976) surveyed all doctors graduating in 1974 and asked them about career choice.General practice (32.9%) and medicine (22.5%) were the first two choices with psychiatry coming in sixth at 3.7%.However, the percen tage choosing psychiatry as first choice varied from 8.1% at Dundee to none at Charing Cross, St Bartholomew's and St Thomas'.Ellin et al (1986) reported on a similar survey of doctors qualifying in 1983.Psychiatry was still the sixth most popular choice, this time with 4.1% of respondents making it their first choice.Again the range was wide with Nottingham producing the most psychiatrists (8.2% first choice) and Sheffield the least (0.9%).Similar differences between schools have been reported in the USA (Weissman et al 1994).In the UK there has been a steady movement towards gender bal ance among medical qualifiers over the last 25 years.This may be of relevance to recruitment into psychiatry as there is some indication that female students have more positive attitudes towards psychiatry (Alexander & Eagles, 1986) and are more likely to opt for psychiatry as a career choice (Shelley & Webb, 1986).
One possible explanation for these different recruitment rates is the impact of undergraduate psychiatry teaching on recruitment.In the UK, Wilkinson et al (1983) and Creed & Goldberg (1987) have both reported more positive atti tudes to psychiatry, and an increase in the number of students planning a career in psy chiatry, after completion of an undergraduate psychiatry attachment.More recently, Singh et ai (1998), when comparing two styles of psychia try teaching, found that attitudes towards psychiatry were already favourable before the attachment and became more so after teaching by either method.These findings have been replicated in other countries.Sierles & Taylor (1995) reported a steady decline in recruitment to psychiatry in the USA since 1970 and concluded that psychiatric recruitment increases proportionally to the resources devoted to producing psychiatrists as well as the priority given to psychiatric educational programmes.
Once career choices have been made they are remarkably stable.Edwards et al (1997) report on early medical career choice and eventual careers of those qualifying in 1983.Of respon dents who had indicated a first choice of psychiatry in their pre-registration year 78% were employed as psychiatrists 11 years later in 1994.The most likely alternative career was general practice (10%).
There seems to be, therefore, convincing evidence that positive attitudes towards psychia try at the end of undergraduate education influence career choice and that a major deter minant of positive attitudes is exposure to well organised and well taught psychiatry pro grammes.How then, might recent changes in undergraduate medical education influence stu dents' attitudes towards psychiatry and their selection of psychiatry as a possible career choice?

Tomorrow's Doctors
The CMC, through its Education Committee has responsibility for promoting and coordinating medical education.In 1993 it published recom mendations on undergraduate medical educa tion -Tomorrow's Doctors (CMC, 1993) which have had far reaching effects on undergraduate learning.The CMC's recommendations can be summarised briefly as follows.

Core and special study modules
The core curriculum is denned, including appropriate knowledge, skills and attitudes.Special Study Modules (SSMs) should enable students to study, in depth, areas of interest to them, develop a questioning and self-critical approach and gain insight into the scientific method.
There is a significant emphasis on commu nication skills, on understanding the social and psychological context of illness, and on assisting students to acquire appropriate attitudes for practice.

Integration
The CMC report advocates systems-based teach ing with horizontal integration within years, and of vertical integration across years, of the course.

Patterns of health care
Teaching and learning must take place in primary care and the community as well as in hospital.Students must have a greater under standing of public health issues.

Organisation of teaching
The focus of learning should be centred around small group, problem-solving approaches and away from large group didactic teaching.Assess ment methods should genuinely assess skills and attitudes.Effective and interdisciplinary supervisory structures must be in place.
Psychiatry teaching is clearly going to con tribute to core teaching in any new curriculum although it is interesting to debate what aspects of psychiatry might constitute the 'core' if the pre-registration house officer is the reference point.One answer is provided by the Education Committee of the Royal College who have suggested a core curriculum for psychiatry in response to the publication of Tomorrow's Doctors (Royal College of Psychiatrists, 1997).The World Psychiatric Association have also suggested a core psychiatry curriculum along with some very helpful suggestions about how this might be taught in undergraduate courses [World Psychiatric Association & World Federa tion for Medical Education, 1998).However, there are other aspects of Tomorrow's Doctors that might allow psychiatrists to contribute to undergraduate education.
(a) The demand for more integrated teaching affords additional opportunities for teach ing psychiatry as part of general medicine and paediatrics.(b) Vertical integration brings opportunities for links with behavioural scientists and neuroscientists, teaching system-based courses in the early years and wanting to introduce clinical relevance and clinical examples.
(c) The emphasis on public health will create possibilities for a focus on mental illness given the prevalence of mental health problems and their current emphasis in Health of the Nation targets.(d) Psychiatrists who want to become more involved in teaching and promote their speciality are well placed to offer teaching in the community.(e) The emphasis on a holistic approach and the need to consider illness in family and social perspectives, while not being a prerogative of psychiatric practice, affords opportunities for psychiatrists and beha vioural scientists to become involved in almost all areas of the curriculum.(f) Perhaps the greatest opportunity of all to influence students will come with the SSM programme.In the future, graduating medical students will not all be the same.They may have acquired the same core knowledge and skills, but will also have spent significant amounts of time engaged on SSM projects.Different schools are interpreting this recommendation in dif ferent ways, but most will have at least some time in the course when students can make a free choice to engage in project work.This is a marvellous opportunity for psychiatrists to offer a range of interesting and stimulating projects for students to work on.If the projects are well con structed, well supervised and help the student achieve relevant objectives, word will spread and more students will want to become involved.This is a chance to influence career choices by encouraging students with an interest in psychiatry to explore the subject in greater depth.

Discussion
There is good evidence that the quality of under graduate psychiatric teaching and its promi nence in the overall curriculum influence career Recruitment, undergraduate education and Tomorrow's Doctors choices.The changes taking place in British medical schools following on from the publica tion of Tomorrow's Doctors provide many oppor tunities for psychiatric departments to re-think the way in which they teach psychiatry.There will be many opportunities to teach, spread throughout the curriculum, both in the core and in SSMs.Given the current shortage of doctors (Campbell, 1997), academic depart ments should seize these opportunities and make every effort to ensure that today's students have a positive experience of psychiatry and become 'tomorrow's psychiatrists'.