Psychiatry recruited you, but will it retain you? Survey of trainees’ opinions

Aims and method To gather opinion from trainees across England about their current experiences and future career plans. This was done via an internet-based survey. Results Out of the 359 responses we received, 65.8% of trainees planned to stay in psychiatry until retirement. Trainees felt several issues were problematic, including the attitude of other specialties towards psychiatry, perceived substandard treatment of psychiatric patients by other specialties and implications of New Ways of Working. Clinical implications Despite there being many areas of training respondents were happy with, if attrition is to be minimised, issues such as how psychiatric trainees integrate with the other medical specialties and how the role of doctors in the specialty is perceived need to be addressed.

Retention in psychiatry has been a problem for a long time. Concern was initially raised that there were not enough British trainees to fill the gaps left by those who retired from the profession. 1 Although the vacancy rate for psychiatrists has reduced, at 4.6% in 2010 it continues to be above that in many other specialties: 3.5% for all specialties, 3.6% in general medicine, 2.2% in obstetrics and gynaecology, and 9.1% in accident and emergency. 2 Over the past 15 years there have been many papers published exploring the reasons for the deficit and with the aim of improving recruitment. Some of this work suggested methods of improving retention by changing recruitment, 1,3 but less has been written about the problems faced by those in specialty training and the subsequent effect on retention.
Despite a consistent percentage of UK graduates expressing an early interest in psychiatry, 20-30% of these have been found to not be working in it 10 years post graduation. 4 Several studies have tried to identify why trainees abandon psychiatry as their career choice. 3,[5][6][7] There were consistent themes within their results: poor public image and lack of respect from other specialties, work stresses and training difficulties. 8 In January 2004, an action plan was adopted jointly by the Department of Health in England and the Royal College of Psychiatrists, to address long-standing problems with recruitment and retention facing the profession. 9 Trainees' experiences are monitored through various means, including via Modernising Medical Careers and an annual survey by the Postgraduate Medical Education and Training Board (PMETB). Having completed this feedback, we felt that there was more to say about our experiences.
This study was designed to assess current difficulties trainees may be encountering and how these may affect their career paths.

Method
A survey was constructed using the Survey Monkey website (www.surveymonkey.com). It was piloted to a small group of trainees in South West London and St George's Mental Health NHS Trust and some modifications were made. The 14 English deaneries were contacted and asked to distribute an invitation email to their trainees. The survey opened in September 2009 and closed 3 weeks after the final response in early 2010.
Trainees were asked to provide basic information about themselves and their training. They were then asked to rate how problematic certain issues were for them on a scale of 0-10, where 0 = 'this has never been a problem' and 10 = 'this is constantly a problem'. For each statement they were also asked whether this problem had ever made them consider leaving psychiatry. The issues were expressed in statements, for example 'I have not been well supervised', and came under the headings of 'training', 'working' and 'attitudes'. We included a non-applicable (N/A) option for each statement as in some cases trainees might not feel able to comment (e.g. core trainee year 1 (CT1) doctors would not be able to comment on the annual review of competence progression (ARCP) process as they have not been through it yet).
Respondents were also asked about their future career plans, including how long they planned to stay in the specialty. Aims and method To gather opinion from trainees across England about their current experiences and future career plans. This was done via an internet-based survey.
Results Out of the 359 responses we received, 65.8% of trainees planned to stay in psychiatry until retirement. Trainees felt several issues were problematic, including the attitude of other specialties towards psychiatry, perceived substandard treatment of psychiatric patients by other specialties and implications of New Ways of Working.
Clinical implications Despite there being many areas of training respondents were happy with, if attrition is to be minimised, issues such as how psychiatric trainees integrate with the other medical specialties and how the role of doctors in the specialty is perceived need to be addressed.
Declaration of interest None.
Psychiatry recruited you, but will it retain you? Survey of trainees' opinions the retention to our specialty? Is it just about solving the above problems? Please let us know any ideas you have'. (The questionnaire is available from the authors on  request.) To analyse the results we calculated the median score and interquartile range (IQR) for each statement. We could not include the N/A responses but have specified how many of these there were for each statement and in most cases there were low numbers. For the qualitative data we grouped the responses into 13 broad categories. We then calculated the number of discrete comments in each category and selected three examples for each.

Demographics
The survey yielded 359 responses from trainees. We estimated the number of core and higher trainees in the 14 deaneries in 2009 based on responses to the PMETB survey. 10 This revealed a response rate of 16.1% (based on an estimated 2231 trainees). The majority of respondents (77.2%) were CT/specialist trainee years 1-3 (ST1-3): CT1 18.4%, CT2 27.3%, CT3 31.5%. The rest were mainly higher trainees (ST4 6.7%, ST5 7.0%, ST6 5.6%) and the remaining 3.6% were 'other' -senior house officers or registrars. In terms of age, the respondents were mainly between 26 and 35 years old (78.5%). There was an equal gender distribution, with 47.8% female and 52.2% male respondents.

Deaneries
Four deaneries did not distribute the email to their trainees: Defence, East Midlands, Oxford and West Midlands. The majority of responses came from the London Deanery (46.8%). Table 1 shows the percentage of responses by deanery.

Intention to stay in UK psychiatry
The majority of respondents (65.8%) plan to stay in psychiatry until retirement. However, if people were to leave psychiatry the top three alternatives were: 'leave the UK and continue in psychiatry' (31.2%), 'leave medicine for another type of work' (22.9%) or 'retrain as a GP' (19.8%). We broke this down further to see what effect training outside the UK, deanery and grade had on intention to stay in psychiatry and the top three alternatives people would consider if they left. Over half the respondents (54.1%) obtained their medical degree outside the UK. Comparing UK and non-UK graduates there did not seem to be any difference in the intentions to stay in psychiatry until retirement (64.0% and 68.1% respectively). There was, however, some variation in what respondents would do if they left. Non-UK graduates were most likely to 'leave the UK and continue in psychiatry' (33.9%), 'pursue a career in research' (21.2%) or 'retrain as a GP' (17.5%), whereas UK graduates would 'leave medicine for another type of work' (39.9%), 'leave the UK and continue in psychiatry' (27.8%) or 'retrain as a GP' (22.8%).
Looking at stage of training, higher trainees were slightly more likely to plan to stay in psychiatry until retirement than were core trainees (76.5% v. 63.1%). If they left UK psychiatry, higher trainees would be most likely to: 'leave the UK and continue in psychiatry' (35.8%), 'leave medicine for another type of work' (22.4%), 'pursue a career in research' (16.4%) or 'be caring for my family' (16.4%). Core trainees would also be most likely to 'leave the UK and continue in psychiatry' (31.2%), followed by 'retrain as a GP' (21.9%) and 'leave medicine for another type of work' (21.6%).
Comparing deaneries, more respondents from outside London plan to stay in psychiatry until retirement than those in the London Deanery (71.7% v. 59.0%). If they left, respondents from outside London would plan to 'leave the UK and continue in psychiatry' (31.7%), 'leave medicine for another type of work' (23.5%) or 'retrain as a GP' (19.7%). Respondents from the London Deanery would 'leave the UK and continue in psychiatry' (30.9%), 'leave medicine for another type of work' (22.4%) or 'retrain as a GP' (20.0%). We chose not to break down the results from other deaneries as many of the numbers were very small.

Problems trainees may have encountered so far in their career in psychiatry
Statements were all rated on a scale of 0-10. Tables 2, 3 and  4 show the median scores and IQR for each statement. Also included is the percentage of respondents who have considered leaving psychiatry because of that problem and the percentage who chose the N/A option.

Qualitative responses
Of the 359 trainees who completed the survey, 196 shared their ideas on how to improve retention in psychiatry. Many trainees made more than one comment and so in total 398 discrete comments were made. We grouped them into 13 broad categories.    'There is so much paperwork that people work mechanically and there is actually no sign of warmth in the service we provide.'

Opportunities in training
There was a wide variety of comments regarding opportunities in training and how these could be improved. Suggestions included an increased variety of jobs, improving opportunity to do research, greater trainee involvement in job planning and an increase in medical aspects of training.
'I think that combining the rotational training with neurology, geriatrics, GP and other medical specialties will improve the retention rates, making us believe that psychiatry is still evolving.' 'Improve allocation of rotations based on a preference and success . . . I have been placed in jobs only doing general and old age [psychiatry] for 3 years. This is what would force me to leave the specialty as I am annoyed at being treated as a commodity.' 'More training flexibility with greater variation in the training experiences offered.'

Patient care
Trainees felt improvements were needed in many aspects of patient care, including medical care for psychiatric patients, quality of patient records, and resources available to patients in both in-patient and out-patient settings.
'I think the key issue is resources. My partner is an oncologist, and when we compare what there is to offer our patients, who often have similar levels of morbidity, the difference is staggering.' 'I think a culture of ''need to be seen to be doing things correctly'' is undermining the real patient care.' 'Lack of structured activity for ward patients, lack of availability of psychological and counselling services.'

Assessment
The category of assessment was roughly divided between comments expressing frustrations with the postgraduate

Recruitment
There were several themes in this category, including increasing and improving exposure of medical students to psychiatry and improving the 'quality' of doctors recruited.
'Raise the profile of psychiatry among medical students . . . Unfortunately I know of many trainees who came into psychiatry because it is ''easy'' and ''non-competitive'', with no real ambition to be psychiatrists.' 'It's about inspiring British-trained medical students with . . . enthusiastic consultants who allow medical students to see how fascinating the mind and its disorders are.' 'I find psychiatry is too much of a ''last resort'' option for trainees -it is extremely frustrating that I'm training with people who are doing psychiatry simply because they didn't get into any other specialty and as such [psychiatry] tends to be a dumping ground for poorly competent doctors. This of course then [has an impact] on the reputation of the specialty as a whole which deters people with an interest from entering it.'

Working with others
Comments in this category revolved around interacting with managers, other members of the multidisciplinary team and fellow doctors. 'The pressure from hospital managers is too much and they tend to be pushing us to the wall. They are also too quick to point fingers at doctors when problems arise and they have apparently made the practice of psychiatry very defensive.
[General practice] will always be a better option to escape from hospital managers.' 'I get frustrated most by the reliance of HR [human resources] on locums for all types of staff -I may end up doing extra work because they can't, or don't have computer access, etc.' 'Improve the pay and teaching for HCAs [healthcare assistants], and let them know how valuable they are.'

Teaching and supervision
Some trainees felt that more formal teaching with their consultant was needed, aside from regular supervision. However, several trainees commented that teaching and supervision are areas where psychiatry is stronger than other specialties.
'All academic meetings are led by trainees where presentations are supervised. It would be better if there was more teaching led by consultants who share their expertise in diagnosis and treatment.' 'Better standard of teaching once in the profession, and encouragement to be professional and maintain knowledge and skills.' 'Part-time consultants should not be educational supervisors.'

Support systems
In this category, trainees suggested that improvements in career advice, attitudes to personal difficulties, help with managing stresses at work and greater senior support for their problems were key to improving retention.
'I am currently working with two doctors, one of whom is off sick with stress and the other is on the verge of a similar situation. There is no support for them and no clear lines to follow if the local structures aren't helpful. I'm only 2 months into CT1 and am very disillusioned!' 'I think there needs to be greater focus in training, and during subsequent career, on how very taxing and emotionally challenging it is to work with people who are often in a very emotionally distressed state of mind. In doing so we are the direct recipients of all sorts of anxious, destructive/aggressive projections from our patients. We cannot manage these alone.' 'The main problem with my job at present is [that] I feel very poorly supported, often only being able to get in touch with supervising consultants sporadically. There are no registrars. I feel this is stressful and demoralising, and potentially dangerous.'

Salaries
On the issue of salaries, trainees called for pay scales relative to other careers and complained about unfair remuneration for hours worked and not being compensated for the risks they are exposed to.
'I think proper pay protection/not changing banding during training posts will help as this can be demoralising for doctors. Contracts should be for the whole training programme, not each post.' 'Better pay! I work part-time due to health reasons -my patients on benefits are paid more than me. This is very demoralising.' 'I would ensure that trainees do not suffer a continuous reduction of their income throughout training due to a dependency on on-call supplements.'

Morale
Trainees commented on low morale in the workforce, feeling that improving this would help boost retention. The answer is simple, I will try to work hard, keeping an eye on the changing patterns of working and try to find my place with a realistic approach.'

Limitations
Trainees who are unhappy with training and consider leaving may have been more likely to complete a survey about retention. This may give a more negative picture than is actually the case. In addition, the statements trainees were asked to comment on were framed in a negative way, for example 'I spend too much time on paperwork'. Negative statements may have predisposed people to pessimistic thinking when they filled in the survey. The majority of responses came from the London Deanery and therefore the views of trainees from other schemes have a much less of an effect on the results. The response rate of 16.1% was reasonable for a survey of this kind, however, generalisability may be limited as the majority of trainees did not complete the survey.

Discussion
Only 65.8% of respondents intend to stay in psychiatry until retirement. It is significant that the most popular alternative would be to continue working in psychiatry, but not in the UK. This suggests that it could be that the specialty itself is not the problem but rather it is the way mental health services operate in the UK which is leading trainees to practise elsewhere. It is interesting that training outside the UK did not seem to affect how long people plan to stay in UK psychiatry.
The survey revealed areas many trainees did not seem to consider problematic, for example supervision and teaching. Among other things, supervision was one of the areas targeted for improvement by the 2004 action plan. 9 Therefore these results may be evidence of progress already made.
One issue that appears to cause problems is the amount of paperwork. Clearly, this is time consuming and is a problem that likely extends to other specialties. It is difficult to see how this can be improved. An increase in the number of administrative staff may be helpful, but this is unlikely to occur. Perhaps technology-based solutions such as dictation software could be considered. A perceived lack of in-patient beds also appears to be problematic. Unfortunately, given the current economic situation, this is something that is unlikely to improve, at least in the near future.
There does not appear to be any one problem that in itself would cause trainees to leave psychiatry. However, the highest number of respondents (8.4%) had thought about leaving because they felt the future role of psychiatrists was being eroded by New Ways of Working. Generally, the main theme in terms of dissatisfaction was respect, not only respect from medical colleagues for psychiatrists and psychiatric patients, but also respect for the psychiatrist's role, even within the mental health profession itself. Our qualitative data echoed this, with most comments relating to attitudes towards psychiatry and the professional role.
The National Institute for Mental Health in England (NIMHE) National Workforce Programme (NWP) finished its work on New Ways of Working in March 2009, after 6 years. The NIMHE NWP aimed to improve workforce design and enable new ways of working across the different professions in psychiatry. Vize stated that 'the biggest single worry of those who have concerns about NWW [New Ways of Working]' is the effect on the role of the psychiatrist. 11 The concern is that losing the traditional consultant's role 'will result in a future role that is ill defined and therefore less attractive, and which can more easily be substituted by other professions'. 11 It continues to be essential, both for recruitment and retention, that the role of the consultant psychiatrist is clearly defined and valued, by both the mental health profession and the wider medical community.
It is difficult to get an accurate picture of the retention situation in other countries to compare with our findings in England. Similarly, research has tended to focus on recruitment rather than retention. In the USA, for example, researchers have looked at the problem of having insufficient trainees in subspecialties, including child and adolescent mental health 12 and research. 13 However, there has been some research into retention in New Zealand and Australia; this is likely because of the well-publicised shortages of psychiatrists there and the uneven distribution of psychiatrists in urban v. rural areas.
Two studies from Australasia investigating factors affecting retention identified some similar themes to us in terms of dissatisfaction. 8,14 These included: the amount of contact with other physicians, 8 the prestige of the specialty, 8 the administrative role 8 and 'high stress levels from bureaucracy'. 13 However, trainees also reported difficulties with supervision and professional support, 8 which did not seem to be such an issue for UK trainees. Perhaps this is because in the UK we have benefitted from improvements following the Department of Health action plan. 9 Another UK specialty which has experienced difficulties with training numbers is obstetrics and gynaecology. In 2003, the Royal College of Obstetricians and Gynaecologists (RCOG) set up a working party to look into recruitment and retention of trainees. When Deanery College Advisors were surveyed with regard to both recruitment and retention, few thought retention was a problem. 15 Where it was, they attributed this to 'competing for experience (with midwives and registrars)', 'difficulty with the MRCOG Part 1 examination' and 'lack of further career opportunities'. Similar to the 2004 action plan, 9 the RCOG report focused mainly on improving recruitment, for example by enhancing undergraduate experience, rather than looking in detail at retention of current trainees.
Despite possible improvements, there still remains significant ignorance and stigma outside of the psychiatric profession which appears to be affecting trainees. More needs to be done to raise the profile of our specialty and dispel some of the myths. Several interesting suggestions were made by trainees, such as involving psychiatrists in grand rounds in acute hospitals thus allowing us to present some of our challenging cases to colleagues. Better integration of psychiatry with the other specialties may increase understanding, as we are often separated geographically as well as philosophically.