UK crisis in recruitment into psychiatric training

Summary

Psychiatry recruitment in the UK is in crisis. In this paper we review reasons and solutions for the current predicament, focusing on the UK situation. We assert that there are specific national issues over and above more general and well-established ones, such as stigma and bad-mouthing, which need to be considered. These include factors that are an unintended consequence of recent changes in postgraduate training, as well as the organisation of the National Health Service. We conclude with some suggestions for psychiatrists, whether trainee or consultant, to help address the situation.

Historically psychiatry has not been the most popular medical specialty, although psychiatrists are among the most satisfied doctors in terms of work-life balance in the National Health Service (NHS) and medical students begin their training with a broad interest in the mind. ^1-3 In 2010, after the first round of recruitment for core training year 1 (CT1), only 50% of CT1 posts were filled. This rose to 80% after a second round. Last year, only 78% of the CT1 posts in psychiatry were filled. The failure to attract British graduates has been masked by overseas recruitment, concealing posts that would have been otherwise unoccupied. This also masks the regional variation in recruitment difficulties; in some parts of the country the situation is dire.

This low popularity is a global issue, highlighted in a recent Lancet paper ⁴ and new research from the World Psychiatric Association that identified multiple factors that influence medical student attitudes towards the specialty and offered some recommendations to promote psychiatry (details available from the author on request). However, not all their conclusions may be generalisable given the differences in both training and healthcare systems around the world. The longstanding factors that have dissuaded medical students and newly qualified doctors from pursuing a career in psychiatry have already been well described in literature in the USA ^3,5-10 and there is a growing evidence base in the UK. ^1,11-13 Although individual factors have been identified, the constellation of all the key issues in the UK has not yet been addressed collectively.

The landscape of undergraduate and postgraduate training in the UK for all clinical specialties has changed in the past decade. This may in part explain why now ‘psychiatry is a recruiting, not a selecting specialty’. ¹⁴ We will focus on those factors that are nationally relevant as these may have been overlooked in strategic planning about how to tackle recruitment in the UK and we assert that all psychiatrists, both individually and collectively, can have a role to play in promoting the specialty.

Undergraduate medical education

A well-cited incentive, attracting future doctors to psychiatry, is a genuine interest in the subject. ^2,3 However, for others the very content of psychiatry is viewed as unscientific. ¹³ The specialty can be perceived as low status and not ‘best use of a medical degree’ by relatives, friends and some members of other clinical specialties too. ^3,7 Negative comments or ‘bad-mouthing’ about psychiatry and psychiatrists from other clinicians is thought to deter medical students away from the specialty. ¹¹

In UK medical schools, it is commonplace for most of the students' psychiatric attachment to be spent on in-patient general adult wards. Learning about psychiatry in an in-patient setting allows students the opportunity to witness complex psychopathology and be involved in the management of higher risk cases. Although this is essential to developing competencies needed for a trainee, it is worth asking whether it is so necessary for an undergraduate. Furthermore, seeing only the most unwell, challenging cases may lead to a skewed perception of patients with psychiatric conditions. In some mental health units, as in many wards across the NHS, ward issues such as overcrowding, disrepair coupled with low staff numbers and morale may also influence student opinion.

Modernising Medical Careers and the introduction of foundation year posts

In 2005 as part of Modernising Medical Careers (MMC), radical changes were introduced in postgraduate medical training, including 2-year foundation training. This provides a broader foundation then the previous single house officer year, allowing newly qualified doctors to develop a wider general knowledge prior to specialisation. ¹⁴ Psychiatry posts are few on many foundation schemes. A UK audit showed that only 20% of foundation doctors have the opportunity of working in a psychiatry post in current programmes, even though there is capacity for more posts. ¹⁵ New junior doctors are now required to choose their career specialty within 1 year of qualifying. This early career specialisation is more inflexible for those who want to change specialty. This disadvantages psychiatry, as psychiatry is often a career choice for ‘late choosers’, after doctors have had exposure to other branches of medicine. These ‘late choosers’ can make up about half of those eventually opting for psychiatry. ² Nowadays, changing specialty can be difficult, with few agreed transferable skills, and now tends to be more a result of failure rather than a planned and deliberate choice.

Actual experience of a specialty increases recruitment into it; so increasing the number of foundation posts in psychiatry is desirable. ^16,17 This experience also helps provide the training of future doctors to look after the mental health of their patients and think about them holistically. ¹⁸ The current paucity of foundation year posts in psychiatry means less opportunity to reverse negative stereotyped beliefs formed in medical school.

The weakening medical identity

New Ways of Working For Psychiatrists, a best practice guidance report, was developed by the National Institute for Mental Health in England and the Royal College of Psychiatrists in 2005. ¹⁹ It outlines a model promoting distribution of responsibility and leadership within mental health teams. New Ways of Working initiatives mean it is no longer automatic that doctors will lead mental health teams. ²⁰ New Ways of Working promotes efficiency by allowing psychiatrists to delegate more tasks, and with care to be delivered along profession-specific lines, allowing psychiatrists to focus on psychiatric presentations and delivering biological interventions. Some, however, have felt that New Ways of Working has made the future role of the psychiatrist unclear and at least in part, has led to the weakening medical identity of psychiatry. The erosion of the role of the psychiatrist has also been cited by some psychiatry trainees as a potential factor that would make them consider leaving psychiatry training. ²¹ The flattened hierarchy compared with other clinical specialties such as surgery, cardiology and general practice may deter other students whose primary ambition is to be a ‘doctor’ who is a ‘leader’ in the traditional sense, and they may take note of the increasing status difference between modern consultant psychiatrists and their counterparts in other disciplines.

The establishment of mental health trusts by the National Service Framework recommended that all mental health services should be provided for separately. Although this allows successful ring-fencing of money for mental health, it has led to an unintended professional and geographical separation of psychiatry from other clinical specialties. This isolation of psychiatry may be adding to the growing demedicalisation and loss of identity of the specialty. The lack of visibility of psychiatrists to medical students and foundation year doctors in a general hospital, evidenced by their absence at hospital grand rounds and research afternoons, minimises the opportunity for the growing knowledge and evidence base about psychiatry to be shared and to challenge any inaccurate views of the specialty. If psychiatry's medical identity were to wither, then the time devoted to mental health would likewise wither in the medical curriculum.

Academic recruitment

Recruitment into academic psychiatry is also under pressure. The new system of integrated academic training across all of medicine offers a seamless system moving from academic foundation posts, via academic clinical fellowships (basic clinical and academic training); competitive fellowships leading to the award of a doctorate; and finally academic clinical lecturer (ACL) posts. However, psychiatry along with other craft specialties has had problems in recruiting to this career path at the ACL level. Academic career training is now longer than simple clinical training, but this is not unique to psychiatry, and perhaps ensures that only those genuinely committed to an academic career will contemplate this. More of an issue is that traditionally, because psychiatry has recruited significantly later than other branches of medicine, the structure of an academic career in psychiatry has also been different, with people taking their doctorates at a later stage. In the past a doctorate has been an ‘exit exam’, rather than an ‘entry exam’, and usually started during the lecturer stage. Now under the integrated academic training scheme, a completed doctorate is necessary to gain admission to the ACL grade.

Ways forward

Attitudes to any clinical specialty are rarely static. There is a need for exploring attitudes at nodal points in a doctor's career path where attitudes and beliefs about psychiatry are likely to form or shift. ¹ We suggest some timely strategies to be considered at nodal points of a future doctor's career, with examples of successful implementation. Although some strategies are already in place and established in some schools and training schemes, all need further support and investment to be made universal across UK training. We assert that all psychiatrists are able to offer commitment to protect and promote our specialty. Many of our suggestions offer excellent training opportunities in education and management for both core and higher trainees and should be advertised accordingly by training schemes.

Prior to medical school

It is important to encourage school students with an interest in mental health to apply to medical school and also persuade students wanting to be doctors that psychiatry is an option. This can be achieved with a greater presence of psychiatrists at national and local careers events. These are opportunities to instil positive aspects of psychiatry, such as the diversity of the work, good work-life balance and opportunities for flexible training.

Gaining clinical work experience in medicine and psychiatry is now one of the most challenging tasks for applicants to medical school due to health trusts' overconcern about patient safety and confidentiality. Psychiatrists should confidently challenge their trusts by reminding them that just as with medical students, as long as a patient consents to a school student's involvement there is no legal barrier to offer work experience. Given we may be working with patients that lack capacity, the supervising doctor need simply ensure that the student's presence is not harmful in any way to the patient. Innovative opportunities to offer work experiences through setting up formal work experience schemes; offering taster sessions with simulated patients; hosting talks by psychiatrists; and willing patients and local holiday workshops should be considered. This may challenge early stigma and stereotypes young people may have about mental illness. The College's position statement on work experience is now available. ²²

During medical school

Steps have already been taken in many medical schools to promote the teaching and learning of psychiatry, these should be commended and encouraged.

Exposure to psychiatry should not be confined to the psychiatry attachment. Exposure can be enhanced by promoting ‘enrichment activities’ requiring medical schools to actively review the opportunities offered locally, nationally and internationally to students (details available from the author on request). These include psychiatry special study modules (SSM) or student selected components (SSC), electives and special university societies. In addition, the College recently announced new ‘Pathfinder’ fellowships for medical students, ²³ giving substantial financial support for a range of enhancement activities, including research, electives and other opportunities.

Anecdotally, London medical school tutors report that special interest groups have improved medical student attitudes to, and the take up of, the specialty. The ‘Extreme Psychiatry’ extracurricular course offered to King's College third-year students (www.extremepsychiatry.wordpress.com) has been very well received and subscribed, as is the Bart's and The Royal London ‘Psych Soc’. Both societies are active on social networking sites, allowing regular sharing of information.

A recent SSC at the Maudsley Hospital for mentored research in psychiatry, which supported students to take projects through to publication, was evaluated showing promising results (details available from the author on request). Student psychotherapy schemes, first introduced in the UK at University College Hospital, have been shown to successfully interest students towards a career in psychiatry who had not previously considered it, and may explain in part the institution's historically above national average number of students choosing psychiatry. ²⁴ These success stories highlight that commitment and innovation by psychiatrists do indeed promote the specialty. The Royal College of Psychiatrists now also has web pages detailing how to set up a new society ²⁵ and how to have an existing society affiliated to the College. ²⁶

In 2009, the Institute of Psychiatry and the Royal College of Psychiatrists hosted the first Psychiatry Summer School to inspire medical students and foundation doctors to consider a career in psychiatry. It has now become an annual event with very positive reviews and has been adopted by other regions in the UK. Details of upcoming summer schools are listed under events on the College's web pages for students and foundation year doctors. These web pages are a must for those students and foundation year doctors showing an interest in psychiatry as there is a wealth of resources, articles and podcasts, as well as details about how to become a free Student Associate member of the College, with benefits including e-subscriptions to the College's journals and free access to many College events. ²⁷

When planning undergraduate psychiatry attachment for students, medical schools may want to consider moving placements from acute in-patient settings to liaison, community or the subspecialties in order to provide a more enjoyable experience. This would allow students to see a wider range of patients with psychiatric conditions including those with less severe diagnoses and better prognosis. The Maudsley Hospital as part of King's College School of Medicine is strategically moving more teaching from in-patient to general hospital settings. Liaison psychiatry placements allow students to see patients with problems that are relevant to all medical practice. Additionally, it is essential to ensure that in-patient mental health wards do offer a safe and comfortable learning experience for students. Trusts may need to be reminded that they receive considerable funding to support student teaching via the service increment for teaching (SIFT) budget – and medical schools have a responsibility to audit this.

After medical school and the foundation years

With only a narrow time frame available to recruit potential psychiatrists, improving the exposure of psychiatry to newly qualified doctors needs to be prioritised. An increase in the number of foundation posts is a key step in this process. In recognition of this the Medical Programme Board of Medical Education England (MEE) has recommended that postgraduate deaneries/foundation schools provide at least 7.5% of foundation year 1 (FY1) posts with a psychiatry component for the August 2013 intake, and that at least 7.5% of FY2 posts should include a psychiatry post for the August 2014 intake. This will mean that at least 22.5% of both FY1 and FY2 doctors will rotate through a placement in psychiatry. What must be avoided, however, is to convert current core psychiatry posts to furnish these foundation posts. Reducing the number of CT posts in psychiatry would be a perverse way to tackle underfill in the specialty. There are sufficient unsuitable posts in other medical and surgical specialties that can be converted to accommodate the proposed experience in psychiatry. Use of simulation (both actor and computer) as well as ‘taster’ sessions (1 week elective specialist experience) may also allow those doctors who do not get a psychiatry post to get some practical experience of psychiatry. Setting up and evaluating such experiences offers a dual incentive as an excellent training opportunity for current trainees.

Medical Education England is introducing ‘broad based training’ structured CT schemes, to include psychiatry posts alongside paediatrics, general practice and accident and emergency in the rotation. This may provide a pathway of training that allows a broader medical experience before specialising and also a possible career pathway for the ‘late choosers’ of psychiatry who could apply to enter core training at the CT2 level thereby extending training by only 1 year. This proposed initiative should be welcomed as they may go some way to reversing the limitations placed by MMC on developing advanced medical training prior to specialising.

Recruitment strategies need also to be reviewed to allow more permeability into the specialty for the ‘late choosers’ who may have started in other specialties. These include giving trainees from other specialties the same opportunities to experience psychiatry that is offered to foundation year doctors, such as the time-limited student associate membership to the Royal College of Psychiatrists allowing access to events and summer schools. An agreement between psychiatry and other specialties about a greater range of transferable competencies would also encourage trainees to consider changing.

Competition for academic foundation posts in psychiatry is fierce but the number of posts remains small. The numbers should be increased alongside the proposed overall increase in non-academic foundation posts. Consideration should also be given to a greater flexibility in academic training pathways. The recent report from the Academy of Medical Sciences on Strengthening Academic Psychiatry in the UK has proposed relaxing the requirement for a doctorate before being appointed to the ACL grade. ²⁸ A quick survey of the 60 current professors of psychiatry at the Maudsley Hospital showed that only 3 would have been able to enter the lecturer grade under the current arrangements, suggesting that flexibility does not mean lowering standards.

Psychiatry trainees and consultants have a responsibility to also narrow the gulf between psychiatry and other clinical specialties. Playing a more prominent role in the teaching and management of medical education at both undergraduate and postgraduate levels in both psychiatric and other non-psychiatric events (communication skills and ethics workshops, hospital grand rounds and hospital research events) is a good starting point. It could also be argued that education of senior medical colleagues in other specialties might help. This could include mental health awareness within general hospital trust induction and also linking it to the continuing professional development component of the new proposed revalidation process. There should also be a greater intolerance to undermining opinions expressed by colleagues from other specialties, and these opinions should perhaps be seen as undermining behaviours that have the same disciplinary consequences as if they were aimed at members of the doctor's team.

In order to ensure brevity we have of necessity given only key details of numerous ways in which psychiatrists, both as trainees or consultants, can improve recruitment to our specialty. Further details can be found in the key 5-year recruitment strategy document of the Royal College of Psychiatrists. ²⁹