Recruiting and retaining psychiatrists

No reader of this journal needs reminding of the importance of the need to attract recruits into psychiatry and to retain those who do choose a career in the psychiatric specialities.

It is pleasing, therefore, to see an attempt being made to search the literature for studies that can enlighten us as to the issues involved (Brockington & Mumford, 2002, this issue). Particularly encouraging is the international level of the search. Those of us working in the UK are understandably preoccupied with the National Health Service (NHS) but, as Brockington & Mumford point out, although we are relatively poorly staffed compared with the USA we are richly provided for in comparison with the huge tracts of Africa or South Asia that are without psychiatrists.

The dearth of recent work is illustrated by the fact that of the articles found in the original search less than half were published in the past 20 years. It may be that some articles have been missed because not all authors include key words such as ‘recruitment’ in their title, such as the valuable work of Firth-Cozens et al (1999) looking at factors affecting choice of future career in medical students.

THE PROBLEM

It is interesting to note that in 1970-1974 work was published indicating a 25% vacancy rate for consultants in the NHS. This compares with an overall figure of around 14% in the Royal College of Psychiatrists 1998 Census (Royal College of Psychiatrists, 1999). However, even in this regard it needs to be pointed out that the problems are confined largely to England. Recruitment is good in Ireland and the situation shows signs of improvement in Scotland. This may be because Scotland and Ireland have more medical school places relative to their total population than England does or it may reflect a higher quality of working life due, at least in part, to higher consultant establishments.

The Parkhouse data (Lambert et al, 1996) indicate a fairly steady proportion of graduates of UK medical schools choosing psychiatry and it could be argued that all we have to do is to wait for the increase in medical school intake to feed through into our postgraduate training schemes. Such complacency should be discouraged because there is evidence to show that enthusiastic teachers recruit enthusiastic future psychiatrists (e.g. Brook, 1983). It is suggested that an increase in the time devoted to psychiatry in the undergraduate timetable is not cost-effective in terms of improved recruitment, but surely it is a matter of quality not quantity.

One of the attractions of psychiatry, particularly to female entrants to the profession, has been that training in the speciality has been more compatible with a normal family life than other specialities (Eagles, 1996). As other specialities improve their training programmes and reduce their working hours this may not remain the case.

Questions now are being asked of us to define more closely what the role of the psychiatrists should be and whether there are tasks currently carried out by psychiatrists that could be carried out more appropriately by other professionals or even workers with no formal professional background. Other medical specialities are being forced to look at such matters. Some of the impetus for such thinking has come from the need to improve the lot of the pre-registration house officer in the NHS and pilot studies have been carried out to show that much routine work (e.g. form-filling, blood-taking and delivery of specimens) could be assigned to other workers. Even case history taking has been delegated (Royal College of Physicians, 2000). What are the psychiatric equivalents of such duties? Could others carry out history taking? The authors themselves quote the assessment of deliberate self-harm patients by liaison psychiatrists. There is long-standing work indicating that nurses, social workers or pre-registration house officers can carry out equally effective assessments as psychiatrists but in most units psychiatrists supervise them. Is this supervision necessary? What does it achieve?

Associated with the topic of recruitment is that of retention. There are two crucial time points in the career of a psychiatrist when there is a danger of the loss of that doctor from the profession. The first is during the early years of training when it is easy for the young psychiatrist to change to an alternative career. Cox (2000) has reported a disturbingly high proportion of doctors leaving the profession after passing the first part of the MRCPsych examination and not going on to complete their postgraduate qualification. Surprisingly, given the high priority given to the supervision of trainees by consultants by the Royal College of Psychiatrists since its inception, many trainees cited poor supervision as one of the reasons for leaving psychiatry. The second time point in the professional career where there is a heavy loss of personnel is when the senior psychiatrist becomes able to retire financially. In the NHS this time point is often at the 55— to 60-year age group because of the enhanced pension benefits offered to those with mental health officer status. This benefit now has been withdrawn for new entrants to the profession but the effect of this change will take around 20 years to work through the system. What we do not know is whether this change will affect recruitment into the speciality. Although those currently reaching retirement age may not have considered, or even been aware of, such matters in making their career choice, different factors may be taken into account by current entrants into the profession. Kendell & Pearce (1997) reported on the reasons given by psychiatrists who retired prematurely. Those reasons are many, but the great majority of subjects reported their enjoyment of and their wish to continue clinical work.

Psychiatrists report higher levels of stress than other doctors and this often is given as a reason for wastage from the speciality. Firth-Cozens' work on the inter-relationship between factors leading to choice of career and perceived stress is interesting, although the number of psychiatrists in her survey was low. However, if it is true that, as her work suggests, the very factors that lead an individual to choose a career in psychiatry also make the individual more susceptible to stress, then the implications are tantalising. Should we attempt to ‘screen out’ those who may be vulnerable to stress? If we do that, then we are likely to lose the very qualities of empathy and sensitivity, which many would regard as desirable attributes for a psychiatrist. Fortunately, there are also findings indicating that it is possible to learn techniques in order to reduce the levels of occupational stress (e.g. Ramirez et al, 1996).

SOME SUGGESTED SOLUTIONS

There is an assumption in Brockington & Mumford's paper that changing the admission criteria to medical schools to allow in more students with non-scientific entry qualifications would improve recruitment into psychiatry. Others (e.g. Thompson & Sims, 1999) have argued that it is the divorce of psychiatry from the mainstream of medicine that has led to the relative unpopularity of psychiatry. There is some evidence to support this, in that quoted papers from the USA indicate that students carrying out placements in liaison psychiatry are more likely to pursue a career in psychiatry. There is evidence also that students perceive psychiatrists as less scientifically rigorous than other specialists and that, far from encouraging them, this makes the speciality less attractive. Cottrell (1999) has argued that the new undergraduate curricula, which encourage more scientific enquiry by students, are more likely to increase recruitment. Do we want to be regarded as less scientific than colleagues in other medical disciplines? Is there a danger that our colleagues in clinical psychology and mental health nursing will be more scientifically qualified than ourselves?

Although pre-registration posts in psychiatry offer valuable experience in the speciality for those going on to practise in other areas (particularly primary care), O'Dwyer (1999) found that comparatively few went on to become career psychiatrists. It could be argued that intending psychiatrists should spend the entire pre-registration year gaining experience in medicine, surgery or primary care rather than spending part of this valuable year practising a speciality that will occupy them for the remainder of their working lives.

The review by Brockington & Mumford ends with the customary call for more research and suggests that this should focus on the pre-registration year and beyond. It could be argued that at least equal attention should be given to further elucidating factors that lead to choice of speciality and to how we can ensure that those who do choose psychiatry are offered appropriate training, supervision and support to enable them to continue and enjoy their careers.