Psychiatry in crisis

Authors: Kathy Oxtoby 

Publication date:  27 Aug 2008

As recruitment hits a new low in the specialty, Kathy Oxtoby asks what needs to be done about psychiatry

When Clare Oakley was considering her future in medicine, a career in psychiatry was the last specialty on her mind. In fact, she remembers “dreading” her psychiatry placement.

“I wanted to be a surgeon, to work in a ‘decisive’ specialty which was all about curing people.”

Psychiatry, she thought, would be “grey and woolly.” On her placement, however, she was “lucky enough to work with an enthusiastic and welcoming team, and I found psychiatry wasn’t grey at all.”

This experience inspired her to want to become a consultant psychiatrist. But not everyone shared her enthusiasm for the subject.

“While I was doing surgical jobs in a hospital, I asked my surgical consultant if he would write a reference for a job I was applying for in psychiatry. He said it ‘was a waste’ that I wouldn’t be a hospital doctor.

“Unfortunately such attitudes to the specialty are pervasive—and they’re putting students off.”

In fact, the specialty is such a turn off for trainees that according to the Royal College of Psychiatrists, only 6% of people who took the exam for membership of the college (MRCPsych) were UK graduates.

“It’s an extraordinary figure,” says the college’s dean, Professor Robert Howard. “We’ve known for a long time that only 2% or 3% of people at medical school want to become psychiatrists, but it appears that things have got worse over the past couple of years.”

There are also huge numbers of training posts. But the lack of competition to fill those posts has dire consequences for the specialty, he believes.

“We’ve always been dependent on first class overseas graduates and we welcome people from all over the world coming to the specialty to train. But we also want competition for entry to our training schemes or we will get weaker people coming in.”

Psychiatry has never had the popularity and glamour associated with specialties such as surgery, and there are fewer opportunities for private practice with the associated financial rewards that go with it. But now the specialty is also facing a lack of confidence resulting from a lack of funding, Professor Howard believes.

“Psychiatrists are often rather apologetic about themselves and the service they have to offer.

“While there are excellent services, mental health has not been funded adequately and in many cases mental health trusts have been raided for money to support acute trusts.”

Negative public perceptions of patients, fuelled by the media, have contributed to the stigma associated with psychiatry. This in turn has become associated with those who work in the specialty some believe.

“We suffer from the same stigma that affects our patients,” asserts Professor Simon Wessely, head of psychological medicine at the Institute of Psychiatry, King’s College, London. “There’s a lot of misunderstanding and myths about the specialty and people harbour suspicions about psychiatric patients and their doctors.”

Professor Wessely also attributes the current “worrying levels” of recruitment to the fact that successive governments have pushed psychiatry back to its traditional remit of caring largely for patients with severe mental illnesses. He believes that there is a danger this is skewing trainees’ perceptions of the specialty. “Inpatient wards can be intimidating—students can end up thinking that’s all there is to psychiatry.”

He adds that medical graduates who want to “treat, diagnose, and assess” are being put off by the fact that some psychiatrists are critical of the medical model and believe curing mental illness requires a change in society.

Another challenge for psychiatry is that only a small proportion of the training curriculum is devoted to it. “At my medical school I had just eight weeks of psychiatry during the whole five years,” recalls Dr Oakley.

Given this lack of exposure to the discipline it is hardly surprising that some doctors have a negative attitude towards psychiatry, which they then pass on to their students.

Add to these difficulties the lack of teaching role models because of the push from universities to publish academic research rather than inspire students, and no wonder the specialty is in crisis.

The college has responded with a review of postgraduate medical training in psychiatry. Initial research commissioned by the Association of University Teachers in Psychiatry in 2005, showed huge variations in how major aspects of the specialty are taught and in the time spent in placements—from 12 to just four weeks. The study also showed that medical students were not always getting the teaching they needed in their early years of training.

On the back of this work, in 2007 the college founded a scoping group on undergraduate education in psychiatry led by Dr Nisha Dogra, a senior lecturer in child and adolescent psychiatry at Greenwood Institute of Child Health, University of Leicester. The group aims to develop a core curriculum for undergraduate psychiatry and to provide guidance on how to deliver and assess this.

“We hope to improve the quality of undergraduate medical education, find out the needs of students and teachers, and develop more coherent guidance about what the curriculum needs to contain,” explains Dr Dogra.

She adds that by November this year, the group hopes to “pull together work done and think about how to use it to move forward.”

A website to promote psychiatry to medical students; a network to share good practice; and ways of providing training support for clinical teachers are being developed by the group.

As part of the college’s action plan, academic psychiatrists in the UK are being asked to focus on undergraduate training.

“We’re asking them to wake up to the challenge,” says Robert Howard. “I’ve said to them that they’re a ‘sleeping giant’ and if they could only get together and focus their effort on the undergraduate experience that could have a huge effect.”

The college hopes to encourage consultant members to receive training in how to teach and it wants to give them bargaining power to negotiate job plans that include, for example, a week dedicated to undergraduate training.

On 11 September the college will hold an action planning meeting, which will be attended by those within the college who are involved in training as well as representatives of major stakeholder groups in undergraduate and foundation training. But Professor Howard says that if the campaign to boost psychiatry is to succeed, input from psychiatry trainees is crucial.

“We want trainees in charge of the campaign. They are closer in age and experience to the people we are trying to attract. And, as young, inspiring doctors, they are fantastic role models who can dispel the kind of stereotype people outside of psychiatry have of the discipline,” he says.

These role models can help to spread the word that psychiatry is a rewarding and fulfilling specialty. Getting people interested in the specialty is half the battle to beating the recruitment crisis, Professor Howard feels.

“We know once people look at psychiatry and see what it’s about, they’ll realise how fantastic it is.”

Greg Lydall, a specialist registrar in general adult psychiatry based in north London, believes a publicity campaign aimed at promoting the value of psychiatry as a career and at eliminating the stigma associated with mental health, would also help attract new recruits.

He urges young and enthusiastic psychiatry trainees to inspire medical students, to “demystify the myths” surrounding the specialty and to remind them that even if they are determined not to work in the area, “a good working understanding of the processes and the basic management is essential to being a well rounded doctor.”

Mending broken bones might be appealing to some, “but if you want to fix a broken mind—now that’s a real challenge,” he says.

Trainee Clare’s experience strikes an optimistic note for the specialty and is proof that if only young medics can be inspired to join the discipline, its daily challenges and rewards will make them want to stay.

“Psychiatry is living up to my expectations. Every day I come to work I still don’t know what challenges there might be. I’m learning loads, there’s still so much more to learn. And it’s never boring.”

Ollie White, specialist registrar in child and adolescent forensic psychiatry

“As a doctor, getting to know patients as people, rather than just as illnesses or diseases, is important to me.

“With psychiatry you have to consider every aspect of the patient’s life: their relationships at home, their difficulties at work are all relevant.

“Being able to improve the situation of people who are acutely unwell can be particularly rewarding. I remember one young girl with bipolar disorder who had spent a long period in hospital. We helped her to understand her illness and prescribed medication to help stabilise her mood. She’s doing well now and is back at school studying for her A levels.

“Psychiatry needs more role models. When I was at medical school, one junior doctor in psychiatry really inspired me—he made me feel it was a cool thing to do. You do think when you’re choosing a specialty, ‘What will my medical school mates say?’ But because I was so inspired by psychiatry it felt OK.

“Some of my friends from medical school are actually quite jealous that when I’m on call I don’t have to stay in hospital overnight.

“Working in the community also makes the specialty attractive. These positives need to be promoted more.

“To anyone thinking of doing this specialty, I would advise them to get more experience of it. Psychiatry doesn’t suit everyone—you need particular skills in speaking and listening to patients. But if you are interested, don’t be put off by its negative image, just give it a go.”

Competing interests: None declared.

Kathy Oxtoby freelance journalist London

Cite this as BMJ Careers ; doi: