Foundation for what? Commentary on … Current position of psychiatry in UK foundation schools

Summary

Two years of foundation training were added to the medical students' transition from learning theory in medical school to trainee clinical practice, replacing one year of house jobs or internship. In the recent few years there has been a tremendous amount of debate about undergraduate medical training and changes in regulations which led to the Collins review in 2010. The review proposed that trainees need more exposure to community-based placements such as psychiatry, public health and community paediatrics and that they also need to learn to deal with chronic conditions. Bearing in mind that nearly a third of the general practitioner's patients will have psychiatric problems, it is essential that all doctors gain some exposure to psychiatric practice. It is crucial that this exposure is appropriate and adequate so that the next generation of doctors can provide accessible services that patients will be willing to use.

Foundation year training was introduced as a result of the report on Modernising Medical Careers. ¹ The pre-registration house office (PRHO) year gave way to the 2-year foundation training programme. Although the equivalent of PRHO year remained, rather than having two 6-month placements in medicine and surgery as before, three 4-month placements were introduced in several places. In addition, a similar arrangement was put in place for the second year, although doctors obtain full registration with the General Medical Council (GMC) after completing the foundation year one (FY1). After the completion of 2 years of foundation training, doctors become eligible to progress to specialist training in their chosen specialty.

Advantages of foundation training

The foundation programme is at the heart of safe, effective, efficacious clinical practice. Just as doctors start their professional journey as partly independent clinical practitioners, it is inevitable that different specialties will seek and compete to be included in this period.

Whereas FY1 training allows medical graduates to take an increasing responsibility under proper supervision, FY2 encourages the development of more specialised clinical activity, albeit still under adequate clinical supervision. Acquiring appropriate clinical competencies under supervision as denoted in the curriculum will lead to doctors being ‘fit for purpose’.

One of the major advantages of foundation years’ training is that trainees have a chance to practise in more specialties than just medicine and surgery. In addition to offering longer clinical exposure and generic training, foundation placements also encourage young doctors to build on their theoretical knowledge and education to develop skills for patient care in a broad sense. Being exposed to specialties like psychiatry may make those specialties more attractive. There have been concerns over a number of years that recruitment of UK graduates into psychiatry has been going down, to the extent that the Department of Health has set up a task-and-finish group and the Royal College of Psychiatrists is leading on a number of initiatives to explore the reasons and come up with solutions. There is evidence that a lack of exposure to the subject may have contributed to this waning interest when it comes to choosing a specialty. ²

Foundation training also teaches young doctors about professionalism and team-working. Psychiatry is indeed well placed to offer skills in professional development and team-working but these need to be delivered in an appropriate placement. Thus exposure to psychiatry under supervision and with a clearly developed curriculum will no doubt lead to better rounded doctors no matter what their eventual specialty is. The importance of psychiatry across all medical specialties cannot be underestimated. It is vital that every doctor has clinical exposure to psychiatry but the challenge is to make this experience suitable. There are potential models for this. The Academy of Medical Royal Colleges produced the curriculum for foundation training to be delivered by trainers; this has been revised and is currently out for consultation as a result of the Collins review ³ and recommendations.

What needs to be done?

The care of patients should be the first concern of the doctor. ⁴ This also carries responsibility towards the patients and society at large. It is hoped that a single point of regulatory responsibility, from admission to medical school, through postgraduate training, to continued clinical practice until retirement, will ensure consistency of expectations and standards. ⁴ As is stressed in the GMC document, training should prepare and encourage doctors to become lifelong learners from the very beginning of their careers. Such training will inevitably start with increased supervision, which can then be titrated according to experience and need. Obviously, training and professional needs of doctors vary according to specialty and clinical experience. Therefore managing different stages of training should be integrated along with a development of clear standards at each stage of professional functioning. A good example of this approach is Medical Leadership Competency Framework published by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges, ⁵ where different levels of skills are learnt over a number of years from undergraduate to consultant level.

The current state of psychiatry in foundation training

The audit carried out by Lowe & Rands ⁶ shows that the foundation posts in psychiatry form only a fifth of the number required to ensure that doctors are exposed to psychiatry. The authors also note that further capacity for more training is available. However, as these data are only from deaneries in England, with a major deanery (Oxford) missing, these findings need to be interpreted with caution. Some trends can be drawn. Only one in five doctors will have the likelihood of securing a psychiatry post in their foundation training. To develop a proper workforce, at least 10% of medical graduates from the UK need to train in psychiatry. In addition, a large proportion of other doctors, especially in primary care, must have experience of psychiatry in their training. Lowe & Rands highlight the availability of special interest sessions, so-called tasters, which though not ideal may provide at least limited exposure to the specialty Anecdotal evidence from Scotland suggests that an increasing number of placements in psychiatry at foundation level have in subsequent years resulted in an increase in applications for specialty training.

There is no doubt that more work needs to be done in creating psychiatry placement posts, especially at foundation level. But, more significantly, providing a broader exposure to different aspects of psychiatry and ensuring that trainees experience appropriate placements and gather the right kind of experience should be the focus of future medical training. Then and only then will sustained recruitment and retention be possible. The challenge is to ensure not only that an adequate number of posts are available in psychiatry but that these placements provide the right kind of experience and supervision, so that future doctors, even if they do not choose psychiatry, at least have the right skills to look after their patients in a more holistic manner.