Old age psychiatry became a separate speciality within the NHS in 1989 and is now well established (Reference JolleyJolley, 1999). Specialist registrars (SpRs) holding national training numbers in old age psychiatry may pursue a single certificate of completion of specialist training (CCST) or dual training with general adult psychiatry. Dual training involves 2 years in each speciality while single old age training involves a 3-year training period with at least 2 years spent in old age psychiatry (Royal College of Psychiatrists, 1998).
At the College's Old Age Faculty SpR meetings, concerns have been expressed that trainees are not clear about the advantages and disadvantages of single and dual training. Some trainees express concerns that single certification may in some circumstances limit their flexibility as consultants, or offer second class status. Furthermore, training schemes are perceived to have very different attitudes to training. Some SpRs said their schemes routinely encouraged trainees to undertake single training, while others said their schemes routinely encouraged dual training.
Dual training has implications for workplace issues. Orrell (Reference Orrell1998) has pointed out that dual accreditation lengthens training and consequently reduces the output of trained old age psychiatrists (who are in short supply). For this reason, it has been suggested that dual accreditation is not justified and should not be offered to the vast majority (Reference ShawShaw, 2000). Others have argued that the present system encourages a thriving speciality (Reference GodberGodber, 1999).
The present system seems confused and lacks clarity. For these reasons we surveyed senior and specialist registrars to find out their attitudes to single and dual training.
Method
A questionnaire was designed and sent to all trainees in the country. The old age psychiatry regional representatives were contacted and asked to provide a list of training schemes and scheme organisers in their region. A list of trainees in old age psychiatry was compiled by writing to the scheme organisers requesting a list of trainees on their scheme registered for single old age or dual training. Where there was no response or the regional representatives were unsure, SpRs in that region were asked for the information. A χ2 test was used to measure whether the reported attitudes of the training schemes were associated with the number of single and dual trainees on that scheme.
Results
The response rate was 153/213 (72%). Of these 78% were SpRs, 17% were senior registrars and 5% lecturers. Eighty-seven per cent were full-time and 13% were flexible trainees; 67% of the sample were registered for dual accreditation and 33% for single accreditation. Of those doing single training 15% said their SpR training would include no general adult training. Seventy-six per cent of trainees aimed to be old age psychiatrists, 3% general adult psychiatrists and 21% were undecided. The trainees' responses to the questions asked are shown in Table 1.
Table 1. Trainees' attitudes to single and dual training
| Statement | Agree (%) | Disagree (%) | Don't know (%) |
|---|---|---|---|
| Prefer a unified 3-year training for old age and general psychiatry | 42 (28) | 95 (62) | 16 (10) |
| Prefer all trainees to dually accredit | 18 (12) | 117 (76) | 18 (12) |
| Concerned that Europe does not recognise old age training | 66 (44) | 38 (26) | 45 (30) |
| Concerned that trusts may specify dual training for old age consultant jobs | 74 (50) | 49 (33) | 26 (17) |
| Concerned that the College may say dual training is preferable | 81 (55) | 38 (26) | 29 (19) |
| Concerned that 4 years is too long to train | 34 (23) | 110 (74) | 5 (3) |
| Four years of training will make me a better consultant | 73 (49) | 57 (38) | 19 (13) |
| Two years of general adult psychiatry will make me a better old age consultant | 56 (38) | 81 (54) | 12 (8) |
| I am in no rush to become a consultant and dual training will prolong my specialist registrar time | 85 (57) | 48 (32) | 16 (11) |
| Even though dual registered, I would leave after single accreditation if the right job came up | 64 (48) | 40 (30) | 29 (22) |
Trainees also had the opportunity to list the main factor(s) influencing their decision to opt for single or dual training. Their responses were grouped together under broad categories. Out of 102 trainees registered for dual accreditation, 44 cited greater flexibility and increasing their options as the reason for their choice. Nineteen welcomed the wider training experience and 17 wanted a longer training and, of these, six mentioned a desire to delay the responsibilities of becoming a consultant. Fourteen were undecided about ultimate career; 10 were concerned about needing experience to provide general adult consultant on-call cover; eight were concerned that in the future the College or trusts may discriminate against those with only a single CCST; six made reference to old age psychiatry not being recognised in other countries where they might want to practise; and three raised the issue of private practice. Two trainees were uncertain as to which was the better option.
Twelve of the 51 trainees pursuing single training selected this option because they were clear that this was their career aim. Nine had no interest or saw no relevance in further general adult training. Seven preferred the shorter training time and six trainees pointed out how long part-time dual training would take. One person felt pressured by their rotation, and another felt that old age psychiatry was under threat and planned to leave his/her rotation to pursue dual training elsewhere. Three mentioned concerns about being part of an adult on-call rota and two acknowledged the lack of flexibility in single training. One person called for clarification from the College that those with a single CCST would not be disadvantaged when looking for consultant jobs.
Trainees in schemes that encourage single accreditation were more likely to be registered for single accreditation (P=0.001) (Table 2).
Table 2. Training schemes' attitudes, and the percentage of trainees undergoing single or dual training
| Schemes' attitudes | Number of SpRs on such a scheme | Per cent undergoing single training | Per cent undergoing dual training |
|---|---|---|---|
| Scheme encourages single training | 20 | 68 | 32 |
| Scheme encourages dual training | 11 | 0 | 100 |
| Scheme encourages neither | 86 | 30 | 70 |
Discussion
The majority of trainees did not want either a 3-year unified scheme or for all trainees to become dually accredited. This survey shows that most trainees want a flexible system that offers them the choice of single or dual training in old age psychiatry. Many SpRs commented that the decision on single or dual training should be left to the individual trainee. Substantial numbers of trainees expressed concerns about the way NHS trusts and the College may view single accreditation. These factors appeared to influence their choice, although nearly half of those dual registered would leave early to take up a consultant post they really wanted. Generally trainees seemed to have reasons for their choice of single or dual training, with only a few feeling unsure or pressured by others. Some trainees reported needing to have a second interview to register for dual, while for others this was not necessary. Trainees describe wide variation between schemes in terms of whether they routinely encourage single or dual training. This form of ‘postcode’ training is unacceptable. There needs to be a more consistent approach across training schemes. There should be clearer guidance from the College as to the advantages and disadvantages of the types of training. This could also address the concerns that many trainees have about the status of single training. If reassured, more trainees may choose single accreditation. This may lead to more trained old age psychiatrists filling posts currently vacant.
Acknowledgements
We thank Dr Marudkar and Dr Orrell for their comments on the questionnaire design and the first draft of the paper, respectively.
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