Recruitment in psychiatry: a complex and multifactorial problem

We read with interest the paper that explores the attitudes of those delivering undergraduate teaching in psychiatry as a factor in poor recruitment. ¹ We appreciate that a positive attitude to teaching students is vital in the delivery of education and in creating appropriate role models, but we believe that these attitudes play a relatively minor role in this problem. The reasons for poor recruitment in psychiatry are multifactorial.

In recent years we have seen competition for psychiatry posts gradually decline. ^2,3 One major factor that has contributed to this are the changes to visas for doctors trained outside the UK. International doctors have traditionally contributed significant numbers to British psychiatry, but current restrictions make it near impossible for international graduates to secure training positions.

Psychiatry as a specialty has always been considered somewhat separate from other hospital-based medical specialties, but we have to consider whether geographical and structural changes to mental health services are further reinforcing this idea and contributing to poor recruitment. We have come a long way from the asylum culture, but many psychiatric hospitals remain geographically separate from the main hospital, giving medical students the impression of psychiatry being a ‘Cinderella branch’ of medicine. Similarly, a streamlining of services has often led to a reduced presence of liaison psychiatry within main hospitals, giving an image of an isolated and understaffed specialty.

In years gone by, junior doctors enjoyed flexibility in training that allowed them to experience a wide variety of placements and specialties before choosing a career path. Changes to training have meant that doctors are now under pressure to choose a specialty early in their career, often without the luxury of having been able to explore all available options. As a result, the ‘less obvious’ options, such as psychiatry, may be overlooked. Early exposure to psychiatry through foundation year 1 posts has been suggested, ⁴ but caution should be exercised as we cannot underestimate the general medical experience and decision-making involved in an often community-based or ‘off-site’ placement such as are typical in psychiatry. It would not serve the specialty well to discourage potential applicants through asking too much of an inexperienced junior doctor.

This lack of exposure to the specialty may extend back to undergraduate training, where psychiatry is a comparatively small component of the syllabus and often not experienced until the later years of medical school. As a specialty that is often subject to outdated myths or jokes, the junior doctors and students who are relatively naive to the reality of psychiatry are at risk of adopting such untruths, which thus influence their opinions and, in turn, recruitment rates.

Exploring the factors affecting recruitment is complex. For this reason it is useful for studies such as that by Korszun et al to consider an individual factor. Much of the literature has concentrated on teaching and the opinions of medical students. ⁵ These writers believe that there is a need for further evidence on the opinions of foundation trainees, in particular whether the negative opinions suggested by studies such as this are widespread and affecting recruitment. A study to explore this factor has therefore been undertaken and we aim to release the results to add to the evidence to be used in tackling declining recruitment rates in the UK.

Psychiatry is one of the most exciting branches of medicine. Because of its very nature and complexity, innovation in psychiatry has been slow relative to other specialties. As a result, we now stand at the door of a major revolution in this branch of medicine. We are now where other medical specialties were half a century ago. We now know that one in four of us will suffer from a mental illness in our lifetime and with a vast amount of research ongoing, this remains a very exciting medical branch to be part of.

There is no doubt that we are guilty of underselling psychiatry. The time has come for us to excite the next generation of doctors and open their eyes to a fascinating specialty that will offer a challenging and fulfilling career. To secure the future of psychiatry we need to ensure that we attract the best candidates for training posts, and as such, studies into recruitment will need to continue.