Psychiatric Bulletin (2007) 31: 70-72. doi: 10.1192/pb.bp.106.010801
© 2007 The Royal College of Psychiatrists
What impact do undergraduate experiences have upon recruitment into psychiatry?
John M. Eagles, Consultant Psychiatrist
Royal Cornhill Hospital, Cornhill Road, Aberdeen AB25 2ZH, email:
john.eagles{at}gpct.grampian.Scot.nhs.uk
Sam Wilson, Clinical Teaching Fellow
Medical Education Unit, University of Aberdeen
Jane M. Murdoch, Lecturer in Old Age Psychiatry
University of Aberdeen
Tom Brown, Consultant Liaison Psychiatrist
Western Infirmary, Glasgow
Declaration of interest
None.

Introduction
The Scottish Division of the Royal College of Psychiatrists
conducted a
survey of members and fellows in 2003 on recruitment
and retention within
psychiatry. Responses relating to retirement
intentions 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 be
achieved by enhancing undergraduate teaching in psychiatry.
This
paper will discuss the ways in which undergraduate experiences
may have an
impact upon recruitment.

Recruitment issues
The distribution of consultant vacancies in psychiatry across
the UK is
variable (
Storer, 2002), but
overall 12% of consultant
posts were unfilled at the time of the
Colleges last
national census
(
Royal College of Psychiatrists,
2002). Based
on calculations in 1999, Brockington & Mumford
(
2002) suggested
that
250300 new consultants are required per annum in
the UK for
replacements and new posts. Factors which may affect
this complex equation
include the recent increase in numbers
of medical students, the current debate
about the level of
unemployment among senior house officers, retention rates
of
junior psychiatrists and early consultant retirement. These
issues are
outside the scope of this paper. Our discussion
will proceed on the basis that
our recruitment problems are
likely to persist and, even if they ease, that
it should
be seen as the responsibility of the whole profession to
attract
the brightest and best
(
Pidd, 2003).

How do doctors choose their careers?
The processes which influence doctors in the choice of their
careers are
subtle and complex. McManus
(
1997) espouses the
views that
medical careers can only really make proper
sense to a chaos
theorist and that doctors mostly
still find out about medical
careers in the same way as adolescents
used to find out about sex
through the mistaken, confused
ideas 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 medical career, they
deem many specialties (including psychiatry) to be very attractive options
(Maidment et al,
2003). Over the next 1015 years, a complex set of
push-and-pull factors influence career choice. Lifestyle factors
seem to be of growing general importance
(Tolhurst & Stewart,
2004). Against all the positive factors which may attract people
into a particular specialty, it is necessary to balance repelling factors such
as the impact of bad-mouthing by specialists in other fields
(Hunt et al, 1996).
It is helpful to bear in mind that attracting future psychiatrists takes place
against this complex backdrop.

Medical student selection
Recruitment of good psychiatrists must depend to some degree
on the
selection of appropriate medical students. Petrides
& McManus
(
2004) found that doctors
entering psychiatry
and general practice were more likely to have an
artistic
approach to medicine, seeing, interpreting and
responding
imaginatively to a range of medical, social, ethical and other
problems. In the USA, Sierles
et al
(
2004) found that
before entry
into medical school psychiatrists scored higher
than other doctors in measures
of verbal ability and general
information. Brockington & Mumford
(
2002) noted that entry
requirements for medical schools favour passes in science subjects,
thus
making it less likely that students will possess these
qualities. However, the
increasing proportion of female medical
students may yield more graduates with
a natural aptitude for
psychiatry (
Wilson
& Eagles, 2006).
Inclinations before entry to medical school were deemed to have a large
influence on career choice in only 15% of the graduates surveyed by Goldacre
et al (2004), being
significantly outweighed by factors during their undergraduate experience.
Thus, although psychiatrists should encourage selection of appropriate
students, with respect to recruitment into our specialty it should be accorded
less attention than our interactions with medical undergraduates.

When do psychiatrists choose their specialty?
It is perhaps surprising that preferences before entry to medical
school 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 specialty
before starting medical
school.
One year after graduation, 78% of male doctors and 72% of female doctors
state that they have made a definite or probable choice of specialty
(Goldacre et al,
2004), but in reality career intentions are likely to change in
the early postgraduate years (Goldacre
& Lambert, 2000). For psychiatry, it is encouraging that
significantly more young doctors select than deselect a psychiatric career
during the first three postgraduate years
(Goldacre & Lambert, 2000;
Goldacre et al,
2005). Cameron & Persad
(1984) reported that 58% of
Canadian psychiatrists selected the specialty after graduation, having
observed the frequency of psychosocial problems in other areas of medicine and
the effectiveness of psychiatric therapies. It is hoped that the advent of
Modernising Medical Careers, which will result in doctors making an earlier
choice of speciality, does not reduce exposure to such experiences, with
adverse effects on psychiatric recruitment.

Undergraduate influences on career choice
In their survey of sixth-formers contemplating a medical career,
Maidment
et al (
2003) found
that 49% of respondents considered
psychiatry a very attractive
career choice and
among students expressing a definite intention
psychiatry was the fourth most popular specialty. Something
seems to change
during the undergraduate years. Rajagopal
et al
(
2004) found that only 3% of
students at a London medical
school 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 undergraduate training
acts as a powerful disincentive for recruitment into primary care
(Whitcomb & Cohen, 2004)
and the same may apply for psychiatry. As Gray
(1999) states:
sometimes the whole ethos of a medical school can become dominated by
high technology medicine with a specialist focus. It does seem that the
more exposure students have (to either community or hospital medicine), the
keener they become upon careers in those areas
(Howe & Ives, 2001). Early
clinical experience, which is uncommon in psychiatry, may exert particular
influences on career choice (Littlewood
et al, 2005). Others feel that influences are less
subtle, with direct negative effects on attitudes to psychiatry occurring
during medical and surgical training (Creed
& Goldberg, 1987). Psychiatrists have to work very hard at
neutralizing antipsychiatric socialization experiences in medical
school (Weintraub et al,
1982). In our survey of Scottish psychiatrists, the low status of
psychiatry among 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 clerkship is the most important medical school
influence on recruitment. Several studies have investigated changes in
attitudes of students towards psychiatry and/or to a possible psychiatric
career following psychiatric clinical attachments, and none has found that
attitudes became more negative. Two found no significant change
(Galletly et al, 1995;
Calvert et al, 1999),
whereas more 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
attachments which might give rise to attitudinal changes have been less
common. Attitude changes were similar whether students were taught with
problem-based learning or with a more traditional curriculum
(Singh et al, 1998;
McParland et al,
2004), although problem-based learning may give rise to better
results in psychiatric examinations
(McParland et al,
2004). Positive attitudinal changes were found to be related to
direct involvement in patient care, seeing patients improve with treatment and
receiving encouragement from consultants
(McParland et al,
2003). Being kept busy and experiencing few boring meetings may
also help to improve attitudes (Sierles
& Taylor, 1995). The perceived lack 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 pursuing a career in
psychiatry.
Across the various medical specialties, several undergraduate factors
influence career choice. In their survey of over 5000 new graduates, Goldacre
et al (2004) found
that career choices were greatly influenced for 45% of graduates by experience
of the chosen subject as a student and by a particular teacher or department
for 27%. The importance of a good role model has been emphasised by others
(Watts et al, 1998;
Park et al, 2005).
Not surprisingly, doctors tend to pick subjects in which they feel that they
have an aptitude as students, and this seems clearly to be the case for
psychiatrists (Goldacre et al,
2005). Students seem to place increasing emphasis on the
importance of lifestyle factors in their career selection (Tolhurst &
Stuart, 2004) and selling the merits of flexible, family-friendly
working practices (Pidd,
2003) within psychiatry should enhance the attractiveness of our
specialty.

Conclusions
Many doctors make career choices in the early postgraduate years
and
perhaps the main goal of teachers should be to promote
sufficiently positive
attitudes among students for them to
graduate still considering the
possibility of becoming a psychiatrist.
It is likely that recruitment of the
best graduates may be
enhanced by: encouraging early undergraduate exposure to
psychiatry;
identifying students with an aptitude for psychiatry and offering
them encouragement and career advice; ensuring that students
have busy
clinical attachments in which they see patients who
respond well to treatment;
emphasising the growing evidence
base underlying psychiatric practice;
engaging proactively
with students; and pointing out the potential lifestyle
benefits
of a psychiatric career.

Acknowledgments
Many of the points covered in this paper have been discussed
within the
Royal College of Psychiatrists Scottish Division
Undergraduate Student
Teaching and Recruitment Group (SDUSTARG),
and we are grateful to other
members of this group. We thank
Lana Hadden for secretarial work.

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