in Misc., Thinking about psychiatry

“Who wants to be a psychiatrist?” London Division academic day May 20 2010

“Who wants to be a psychiatrist?” a London Division academic day, was an interesting day of talks, workshops and discussion examining reasons and solutions for the current problems of UK psychiatric recruitment.

Prof Robert Howard, Dean of the Royal College of Psychiatrists, perhaps summed the current situation the most baldly.  “The recruitment crisis is the biggest challenge psychiatry faces”.  Concerning, he also said that this is leading to an “unacceptable variation in quality amongst trainees and consultants”.

The situation does indeed appear to be dire.  This year the London Deanery received 250 applications for core training posts, down from 400 in previous years.  In the country as a whole the competition ratio of applicants to psychiatric training to jobs available is 1:1.  The result, as Michael Maier, head of the London Specialty School of Psychiatry put it, is that “psychiatry is a recruiting, not a selecting specialty”.

Yet despite this, a recent Royal Society of Medicine study found that, alongside general practice, it was doctors who worked in psychiatry who found their lives the most satisfying.  The popularity of the study of psychology suggests that, amongst school leavers, a general lack of interest in the mind and its problems is not a problem; however again and again, upon leaving foundation jobs, doctors in training choose other specialities for a career.

How could this have come about?  Prof Ania Korszun from Barts and the London suggested three culprits: psychiatry is seen as not ‘medical’ or ‘scientific’ enough; psychiatry recruitment suffers by association with the widespread popular stigma surrounding mental disorder; and medical students are discouraged from psychiatric careers by the negative views held by doctors working in other specialities with whom they spend much of their training.

This relentless disparagement directed towards the ears of impressionable medical students appears to be particularly potent.  Dr Gianetta Rands, who talked about psychiatry as a part of foundation training, told us that the longer medical students spend in non-psychiatric specialities the less likely they are to choose a career in psychiatry.  The split between acute trusts and mental health trusts also means that psychiatrists are rarely present – be it at grand rounds or in the canteen – to put forward an alternative viewpoint.  It has been recognised that more psychiatry foundation year placements are required, especially in year one.  There are currently 500 placements over both years, but 2000 are needed.

Psychiatry undoubtedly has an image problem and Dr Peter Byrne, chairman of the Royal College of Psychiatry’s public education committee, presented a fascinating talk about the profile that psychiatrists have in the media and also our role as ‘evidence based public educators’.  An interesting insight was that whilst newspaper stories about physical health most often concerned the stereotype of ‘bad patient’, those concerning mental health focus on that of the ‘bad doctor’.  The recent BBC programme Mental: A history of the madhouse is an example of this.  Dr Byrne encouraged media engagement by psychiatrists and this theme was further examined in a workshop run by Dr Mark Salter, the event’s organiser.  Other workshops tackled writing skills, running student psychiatric societies and making a psychiatric documentary.

Given the current situation, it might have been possible to find some of the messages of the day dispiriting.  Fortunately there were many moments of levity and an overall note of optimism.  Dr Chris Manning, a GP with experience of mental health services from both sides, praised psychiatrists and delivered an enthusiastic panegyric: “Minding the brain – the best job in the world”.  Dr Kate Stein, a foundation doctor, was equally enthusiastic when she told us about her plans for a psychiatric career.  The active role of medical students present as delegates was also welcome and encouraging.

Of course it is not simply enough to identify a problem and there is a plan of action, in which – amongst others – Prof Howard, Dean of the College, is taking a special interest.  He wishes to raise the profile of psychiatry, especially with medical students, and to make medicine in general ‘more psychiatric’.

The day closed with a rabble rousing talk from Prof Simon Wessely “Why psychiatrists still need to be doctors”.  Prof Wessely convincingly argued that patients both want and need their mental health disorders to be treated by psychiatrists who are also doctors.  He spoke of the value of our ability to make a diagnosis and in our use of the biomedical model.  Psychiatrists’ ability to distinguish physical from psychiatric disease makes us indispensible to our physical medicine colleagues.

Psychiatry has in fact never recruited as many UK trained doctors as it needs to fill its posts and in seeking to reverse this phenomenon we seek to overturn a historical precedent.  Improving the situation requires action on many fronts.  It particularly concerns me that we may be recruiting the wrong mix of students to medical school, as current science focused selection criteria favours technical knowledge over a candidate’s potential to flourish into the practitioner of holistic medicine that psychiatric practice requires and may preclude those who will eventually wish to take the path required by psychiatric practice.  A central message of “Who wants to be a psychiatrist?” is that we can all become involved in this debate and every day should regard ourselves as “walking, talking adverts for psychiatry”.


Originally published in the June 2010 newsletter of the RCPsych London Division


Image credit Wikipedia

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  1. With the known crisis in recruitment, it saddened me when an F2 doctor, with whom I worked, had her application for psychiatry core training rejected this year as she sent it at 5pm and 30 seconds, thus missing the 5pm deadline (she had been reviewing a particularly distressed patient and was delayed in submitting her excellent application). Despite much pleading, including consultant support, the Deanery held fast to their deadline and staunchly blocked her from a career in psychiatry. It is attitudes like these that deliberately erect unhelpful bureaucratic barriers to applying for core training in psychiatry. The F2 was offered a job in paediatrics, and psychiatry has lost a potentially excellent doctor for the sake of excessive rigidity and a 30 second delay. Granted she should have submitted the application sooner, but it could also be argued that she should not have been penalised for prioritising appropriate and humane clinical care. Some flexibility and a more enthusiastic and welcoming attitude may go some way to addressing deficits in applications…

  2. This sounds like an extremely hard learned lesson of to whom one must give priority in this crazy world. The interview process and its assessment criteria provide perverse disincentives to be a good clinician.

    My experience of the deaneries is that flexibility is all expected to be one way. My recent application process demains adherence to multiple conditions any of which my failure to meet will find my application rejected (i.e. not bringing certain things to the interview), whereas I have had interview times reorganised with very little notice and perfunctory apology only.

  3. Chris Manning was so optimistic about my mental health he tried to make me famous.

  4. Psychiatry isn’t attractive, on graduating from Med School. I hated, hated my placement as an undergraduate, it was utterly dire with no teaching, no helpful exposure to the speciality and was grim beyond belief. It was only by mistake that I came to psychiatry, after training and time in GP land, that I thought, “I’m home!”

    Part of the reason that it’s not instantly attractice is that to bright eyed bushy tailed young medics, compared to other options, it can seem dull. It’s only after a few years maturity that medics find their discipline of Neurology (routine work, seeing headaches 80% of patients), Orthopaedics (just replacing hip after hip after hip), Cardiology (trying to manage angina as a chronic pain that can’t be cured, day after day) that the challenge and scope and diversity and team working of psychiatry shines. It’s far more varied and arguably more challenging than many specialities.

    Yet, if I go to a room full of undergraduate medical students and ask, “Hey folks, how many of you want to be old age psychiatrists when you graduate?!” you’d be stunned by the silence, lack of raised hands, and tumbleweed blowing past . . .

  5. This is an interesting blog post. As a former psychiatric patient (back in the 60s/70s) whose life was almost destroyed (no exaggeration) by a rigid application of the medical model, I would like to comment on a few points.

    So Prof Ania Korzun suggests one of the reasons for the recruitment crisis is that ‘psychiatry is seen as not “medical” or “scientific” enough.’ Some medical students may, indeed, feel this way. Is this why many psychiatrists seem keen to defend their profession by loudly proclaiming just how ‘medical’ and ‘scientific’ it is? But there is a problem in the biomedical model of psychiatry, isn’t there? A broken bone shows up more clearly on an x-ray than a broken life.

    Having taken part myself in the recent BBC programme, ‘Mental: a History of the Madhouse’, I was relieved to find that the programme makers did not shirk from showing the dark side of the history of psychiatry. Was this documentary balanced? Did it fail to give voice to those who had positive experiences in such places? All I know is that the horrors it revealed were true to what I witnessed and experienced as late as the seventies. There are lessons to be learnt from the past and still a lot of learning to do.

    ‘Prof Wessely convincingly argued that patients both want and need their mental health disorders to be treated by psychiatrists who are also doctors.’ But some, perhaps many, patients do not see what is being defined as ‘their mental health disorder’ as a physical illness requiring physical treatment. I’m not saying that a medical framework is always unhelpful, but many patients have suffered greatly due to the flaws in the diagnostic process and the inappropriate use of the biomedical model. Psychiatrists are not always able to distinguish physical from psychiatric disease (I say this with no criticism as it must sometimes be difficult to do so). Likewise, and perhaps more often, psychiatrists may not be able to distinguish psychiatric illness from social problems.

    The recruitment crisis is not helped when psychiatrists become defensive in response to criticism of their profession, or anxious to prove that they are ‘proper doctors’ with outstanding medical expertise. Why try to make psychiatry appeal mainly to the medical students who prefer black and white thinking, who want clear-cut answers, who believe in certainty and seek it in technical knowledge at the expense of widening their outlook? Wouldn’t psychiatry benefit from an influx of students who are open minded, enjoy interesting debates, ask challenging questions, look at different views and experiences gained from an interdisciplinary approach, are interested in human rights, human beings, social and ethical dilemmas, and the full range of complex issues that make psychiatry the fascinating subject that it is?

  6. during my travels through the system in the mid-1990s it often amazed me how many psychiatrists felt that the words coming out of my mouth, or even the gestures I made with my hands, was an accurate way of gauging how much chlorpromazine or haloperidal to force me to swallow. Who was teaching these sheep? Scandalous.

  7. The UK first introduced graduate-entry medical degrees alongside straight-from-school degrees approx 10 years ago. I wonder if grad-entry students might on average be a bit more open to interdisciplinary approaches and/or a bit more interested in psychiatry.
    Such students might have studied science before, understanding the important role of science, but also be aware that often we have to work around the limits of scientific knowledge. Or they might have studied humanities and gained different perspectives from this. And by definition they will have been around a bit longer, often having been employed in a career other than medicine, and might have a bit more experience of mental health in themselves/ in their own friends. Finally, they’ll often have made the decision to become a doctor when they are a bit older and perhaps more able to see what kind of attributes/ personality are useful in medicine, particularly the holistic rather than the technical bits.
    This is not to say that grad-entry medics will necessarily be more interested/ more appealing candidates than those straight from school, but some of them might.
    (NB I’m pretty biased because I’m a grad-entry student … and hope to be involved in psychiatry in some form in the future!)

  8. Hi there,

    An interesting post. I did my medical degree in the UK and did one year of psych training there before moving to Australia and completing my training here. As a medical student, I LOVED my psychiatry attachment and it was a huge factor in choosing psychiatry as a career.
    Here in Australia, the recruitment and retention problem is even higher, with many training (and consultant) posts vacant. There is a constant battle to have registrars (your SHOs) attached to us, and then to find the time to teach them. One issue here is that private practice is very common, and lucrative, attracting many consultants. The public system therefore has to deal with the sickest, toughest cases: usually acute distress and self harm, and acute psychosis. Med students and trainees see this, and this only, and are overwhelmed.
    It’s a tough one. I am heading back to work next year probably after having 2 babies, and to be honest, I’ll probably go into private practice – compounding the problem, I know. No on call, earn five times as much, pick my own hours, and send acute cases to A&E: who wouldn’t want to do it?

  9. Might Psychiatry’s image problem be something to do with it being regarded as a ‘soft’, ‘easy’ or unscientific option withing the medical profession. Isn’t it a bit like me chosing sociology as my third ‘A’ level. If I did well at it then I could say I’m an expert sociologist when I’m not really, it’s just that what sociology is is open to debate and I might be able to successfully argue that I am good at what I define to be sociology.
    So maybe psychiatry is appealing because it’s vague like socialogy. Trouble is, whilst it might be stimulating having a debate with your fellow students or coleagues about what your role should be, with psychiatry comes responsability that shouldn’t be taken lightly and actually your role is most likely to be someone who drugs and confines people on a daily basis.
    I would suggest that insensitivity to the needs of others as opposed to sensitivity is the quality that enables many psychiatrists to continue working- and Dawn seems to confirm this. Seeing suffering as an illness might seem the only way to manage patients and keep order on the ward – especially if you’ve been trained to think that way. Better to go private where the living is easy and the ‘illnesses’ milder than stay on the front line where psychiatists end up having to maintain the illusion of treatment when they’re actually in many cases causing and prolonging real and terrifying illness.

  10. Hi again,
    Hmmm, I’m not sure if I’m being called insensitive or not, but I’ll try not to be defensive and explain my comments further!
    My comments about private practice were meant to be tongue in cheek in a way, but also perhaps to show what I think is a huge problem in psychiatry: staff burnout. I have worked full time in public hospitals for twelve years. I absolutely love my clinical work, and the time I spend with patients and families. I specialise in child and adolescent psych because I believe that early intervention is the best intervention of all. But I am a person too, and with two children under age 2, I physically and mentally cannot work 80 hours straight (which is what I am required to do when on call). Unfortunately, the lack of clinical staff means that the existing staff work more, and I have no doubt that the patient I see at 5am on my third night in a row with no sleep may not be treated as sensitively as I would wish. So I take your point about people going into survival mode.
    It is a shame that people feel that psychiatrists cause and prolong illnesses, and that is certainly not my experience.
    It is a useful debate to have, as mental health issues are common and serious, and we do need to make sure that we have both the quantity and quality of staff to work with patients and their families. Let’s hope that the academic day discussed above starts to get things moving, improving things for everyone involved in the mental health system.
    All the best,

  11. Being locked up and drugged is terrifying and plays havoc with your mental health.

  12. Perhaps it is different in the U.K., but in the U.S., this is how psychiatry is practiced: I cannot imagine that this sort of practice would be appealing to a medical student. All of the psychiatrists in my area, with the exception of one who allocates 30 minutes per patient, practice this way. They have turned themselves into replaceable specialists who simply scribble out prescriptions and sent people on their way. Well… primary care physicians can do that, too. And people know their primary care physicians, so many don’t see a point in adding yet another physician who will just duplicate a service that they can get from their primary care doctor. But again, perhaps it is different in the U.K. since your system is not quite so profit-driven. I certainly hope it is.

  13. Thank your for your comments. While you make some good pinots, I think it’s important not to confuse the usual teen angst with a serious mental illness. When clinical depression or a bipolar condition is diagnosed, a supportive family is important but sometimes only appropriate medication and therapy can have a lasting impact.Judith Shamian