What impact do undergraduate experiences have upon recruitment into psychiatry?

The Scottish Division of the Royal College of Psychiatristsconducted a survey of members and fellows in 2003 on recruitmentand retention within psychiatry. Responses relating to retirementintentions of consultants have been published previously (Eagles et al, 2005).Respondents were asked to give views about improving recruitment,and by far the most common suggestion was that this could beachieved by enhancing undergraduate teaching in psychiatry.This paper will discuss the ways in which undergraduate experiencesmay have an impact upon recruitment.

Recruitment issues

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Recruitment issues

The distribution of consultant vacancies in psychiatry acrossthe UK is variable (Storer, 2002), but overall 12% of consultantposts were unfilled at the time of the College’s lastnational census (Royal College of Psychiatrists, 2002). Basedon calculations in 1999, Brockington & Mumford (2002) suggestedthat 250–300 new consultants are required per annum inthe UK for replacements and new posts. Factors which may affectthis complex equation include the recent increase in numbersof medical students, the current debate about the level ofunemployment among senior house officers, retention rates ofjunior psychiatrists and early consultant retirement. Theseissues are outside the scope of this paper. Our discussionwill proceed on the basis that our recruitment problems arelikely to persist and, even if they ease, that ‘it shouldbe seen as the responsibility of the whole profession to attractthe brightest and best’ (Pidd, 2003).

How do doctors choose their careers?

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How do doctors choose...

The processes which influence doctors in the choice of theircareers are subtle and complex. McManus (1997) espouses theviews that medical careers ‘can only really make propersense to a chaos theorist’ and that ‘doctors mostlystill find out about medical careers in the same way as adolescentsused to find out about sex – through the mistaken, confusedideas of their peers in the playground’. In this context,the lack of career advice and support to medical students and newly graduated doctors has been criticised (McManus, 1997; Lambert & Goldacre, 2002; Mahoney et al, 2004).

When young people are at the stage of considering a medicalcareer, they deem many specialties (including psychiatry) tobe very attractive options (Maidment et al, 2003). Over thenext 10–15 years, a complex set of ‘push-and-pull’factors influence career choice. Lifestyle factors seem tobe of growing general importance (Tolhurst & Stewart, 2004).Against all the positive factors which may attract people intoa particular specialty, it is necessary to balance repellingfactors such as the impact of ‘bad-mouthing’ byspecialists in other fields (Hunt et al, 1996). It is helpfulto bear in mind that attracting future psychiatrists takes place against this complex backdrop.

Medical student selection

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Medical student selection

Recruitment of good psychiatrists must depend to some degreeon the selection of appropriate medical students. Petrides& McManus (2004) found that doctors entering psychiatryand general practice were more likely to have an ‘artistic’approach to medicine, ‘seeing, interpreting and respondingimaginatively to a range of medical, social, ethical and other problems’. In the USA, Sierles et al (2004) found thatbefore entry into medical school psychiatrists scored higherthan other doctors in measures of verbal ability and generalinformation. Brockington & Mumford (2002) noted that entry requirements for medical schools favour passes in science subjects,thus making it less likely that students will possess thesequalities. However, the increasing proportion of female medicalstudents may yield more graduates with a natural aptitude forpsychiatry (Wilson & Eagles, 2006).

Inclinations before entry to medical school were deemed to havea large influence on career choice in only 15% of the graduatessurveyed by Goldacre et al (2004), being significantly outweighedby factors during their undergraduate experience. Thus, althoughpsychiatrists should encourage selection of appropriate students,with respect to recruitment into our specialty it should beaccorded less attention than our interactions with medicalundergraduates.

When do psychiatrists choose their specialty?

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When do psychiatrists choose...

It is perhaps surprising that preferences before entry to medicalschool do not appear to greatly influence ultimate career choice (Goldacre et al, 2004). In Canada, Cameron & Persad (1984)found that 14% of psychiatrists had decided to enter the specialtybefore starting medical school.

One year after graduation, 78% of male doctors and 72% of femaledoctors state that they have made a definite or probable choiceof specialty (Goldacre et al, 2004), but in reality careerintentions are likely to change in the early postgraduate years(Goldacre & Lambert, 2000). For psychiatry, it is encouragingthat significantly more young doctors select than deselecta psychiatric career during the first three postgraduate years (Goldacre & Lambert, 2000; Goldacre et al, 2005). Cameron& Persad (1984) reported that 58% of Canadian psychiatristsselected the specialty after graduation, having observed thefrequency of psychosocial problems in other areas of medicineand the effectiveness of psychiatric therapies. It is hopedthat the advent of Modernising Medical Careers, which willresult in doctors making an earlier choice of speciality, doesnot reduce exposure to such experiences, with adverse effectson psychiatric recruitment.

Undergraduate influences on career choice

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Undergraduate influences on...

In their survey of sixth-formers contemplating a medical career,Maidment et al (2003) found that 49% of respondents consideredpsychiatry a ‘very attractive’ career choice andamong students expressing a ‘definite intention’ psychiatry was the fourth most popular specialty. Somethingseems to change during the undergraduate years. Rajagopal etal (2004) found that only 3% of students at a London medicalschool rated psychiatry as a career they would wish to pursue.Exposure to clinical psychiatry tends to promote positive attitudes,so it seems that this negativity must derive from non-psychiatric sources.

Overemphasis on acute hospital-based medicine during undergraduatetraining acts as a powerful disincentive for recruitment intoprimary care (Whitcomb & Cohen, 2004) and the same mayapply for psychiatry. As Gray (1999) states: ‘sometimesthe whole ethos of a medical school can become dominated by high technology medicine with a specialist focus’. Itdoes seem that the more exposure students have (to either communityor hospital medicine), the keener they become upon careersin those areas (Howe & Ives, 2001). Early clinical experience,which is uncommon in psychiatry, may exert particular influenceson career choice (Littlewood et al, 2005). Others feel thatinfluences are less subtle, with direct negative effects onattitudes to psychiatry occurring during medical and surgicaltraining (Creed & Goldberg, 1987). Psychiatrists have towork very hard at ‘neutralizing antipsychiatric socializationexperiences in medical school’ (Weintraub et al, 1982).In our survey of Scottish psychiatrists, the low status of psychiatryamong other medical professionals was considered to be the single factor which most adversely affected recruitment.

Turning to positive influences, Sierles & Taylor (1995)stated that ‘most authors believe the psychiatry clerkshipis the most important medical school influence on recruitment’.Several studies have investigated changes in attitudes of studentstowards psychiatry and/or to a possible psychiatric careerfollowing psychiatric clinical attachments, and none has foundthat attitudes became more negative. Two found no significantchange (Galletly et al, 1995; Calvert et al, 1999), whereasmore studies found that attitudes became increasingly positive (Shelley & Webb, 1986; Sivakumar et al, 1986; Creed & Goldberg, 1987;Alexander & Eagles, 1990; Singh et al, 1998; McParland et al, 2003).Studies investigating specific aspects of clinical attachmentswhich might give rise to attitudinal changes have been less common. Attitude changes were similar whether students weretaught with problem-based learning or with a more traditionalcurriculum (Singh et al, 1998; McParland et al, 2004), althoughproblem-based learning may give rise to better results in psychiatricexaminations (McParland et al, 2004). Positive attitudinalchanges were found to be related to direct involvement in patientcare, seeing patients improve with treatment and receivingencouragement from consultants (McParland et al, 2003). Beingkept busy and experiencing few boring meetings may also helpto improve attitudes (Sierles & Taylor, 1995). The perceivedlack of a scientific foundation to psychiatric practice (Malhi et al, 2002)and concerns about over-identifying with patients (Field & Lennox, 1996)can exert negative influences on the likelihood of pursuinga career in psychiatry.

Across the various medical specialties, several undergraduatefactors influence career choice. In their survey of over 5000new graduates, Goldacre et al (2004) found that career choiceswere greatly influenced for 45% of graduates by experience ofthe chosen subject as a student and by a particular teacheror department for 27%. The importance of a good role modelhas been emphasised by others (Watts et al, 1998; Park et al, 2005). Not surprisingly, doctors tend to pick subjects in which theyfeel that they have an aptitude as students, and this seemsclearly to be the case for psychiatrists (Goldacre et al, 2005).Students seem to place increasing emphasis on the importanceof lifestyle factors in their career selection (Tolhurst & Stuart, 2004) and ‘selling the merits of flexible, family-friendly working practices’ (Pidd, 2003) within psychiatry shouldenhance the attractiveness of our specialty.

Conclusions

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Conclusions

Many doctors make career choices in the early postgraduate yearsand perhaps the main goal of teachers should be to promotesufficiently positive attitudes among students for them tograduate still considering the possibility of becoming a psychiatrist.It is likely that recruitment of the best graduates may beenhanced by: encouraging early undergraduate exposure to psychiatry;identifying students with an aptitude for psychiatry and offering them encouragement and career advice; ensuring that studentshave busy clinical attachments in which they see patients whorespond well to treatment; emphasising the growing evidencebase underlying psychiatric practice; engaging proactivelywith students; and pointing out the potential lifestyle benefitsof a psychiatric career.

Acknowledgments

Many of the points covered in this paper have been discussedwithin the Royal College of Psychiatrists’ Scottish DivisionUndergraduate Student Teaching and Recruitment Group (S–DUSTARG),and we are grateful to other members of this group. We thankLana Hadden for secretarial work.

References

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