University of Birmingham
University of Bristol.
Correspondence: David Mumford, Director of Medical Education and Reader in Cross-Cultural Psychiatry, 41 St Michael's Hill, Bristol BS2 8DZ, UK
See editorial, pp.
296297, this issue.
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ABSTRACT |
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Aims To inform the strategy for improving recruitment.
Method A literature review.
Results The number of psychiatrists required depends on the role of psychiatry, which is constantly changing. The present requirement is about 250-300 per year, including replacements and new posts. The number of psychiatric trainees has always been higher than expected from the career plans of newly qualified doctors, but the number of British graduates passing the Royal College of Psychiatrists' Membership examination has still fallen short, requiring a supplement of foreign medical graduates. The recent 50% expansion in medical students may make this country self-sufficient.
Conclusions To improve recruitment, the College should focus on influences before and after undergraduate training the kind of student entering medical school and the factors favouring sustained psychiatric practice after graduation.
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INTRODUCTION |
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PRESENT REQUIREMENT FOR CONSULTANT PSYCHIATRISTS |
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The need is to replace those ceasing to practise and fill new posts. If mental health officers were appointed at age 33 years and retired at 59 years we would need 115 new consultants each year. If the consultant body expanded by 5% per annum, then an additional 150 posts per year would be needed. The total requirement, therefore, lies between 250 and 300 new consultants per year, to which replacements and new posts make an approximately equal contribution.
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SUPPLY OF CONSULTANT PSYCHIATRISTS PRACTISING IN BRITAIN |
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The data show a low but stable level of interest (in the range 2.9-4.2%, mean 3.6%), with a slight preponderance of women (mean: males, 3.5%, females, 4.3%). At the present level of medical student numbers (3614), the number aiming for psychiatry is in the range 105-152 per year, which is well below the required number. With an expansion to 5652 per year it could, at the most optimistic prediction of graduand choice (4.2%), reach 237 per year, which is close to the required number.
The number entering psychiatric training, however, has been greater than that expected from the career aims of graduands. Table 3 summarises data supplied by the President (R. E. Kendell) for those passing the Membership examination.
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The number of successful British candidates has varied from 183 to 238 during the past 10 years, with a mean of 203. The number of medical graduates from continental Europe training in Britain is germane. Data supplied by Damon Ralston showed that the first candidate passed in 1980, and the next in 1989; thereafter, there have been 7-19 per year (mean 13), which is a rather small contribution. Those from the Republic of Ireland will raise the total, but the combination of successful British, Irish and European candidates is below the number required to fill consultant posts. It remains to be seen whether the increase of medical students now in the pipeline will make up the difference.
Overseas recruitment in Britain and America masks poor local recruitment. The number of international trainees has been rising steadily in the USA (Balon & Munoz, 1966; Weissman, 1996). This may not be true in Britain because of emigration rules. The number of successful overseas candidates has been high in recent years at least 70 per year since 1989. If candidates from other countries were allowed to stay, and wished to do so, they should supply any remaining deficit.
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FUTURE REQUIREMENTS |
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The level of morbidity in the population is fundamental. New research may eliminate diseases, but it is more likely that new social conditions will increase them, as we have seen with the growth of substance misuse.
The threshold for involvement of specialists has great influence. Much diagnostic assessment and treatment is carried out in primary care. Even in Britain, some has been taken over by private practice. There is some pressure to restrict public sector funding to the most seriously ill psychoses or those requiring in-patient admission (the old asylum role).
In general psychiatry, a crucial question is whether the consultant's role is confined to diagnosis and prescription (or care planning) or whether it also involves psychological treatment. Comprehensive assessment can be done only by doctors, but psychotherapy and continuing support can be provided by nursing staff, psychologists, social workers and other professionals.
In almost all specialist areas, there are problems of threshold, for example:
The answers to these questions greatly influence workforce calculations.
As in other areas of medicine, the number required also depends on:
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BACKGROUND FACTORS AFFECTING THE RECRUITMENT OF PSYCHIATRISTS |
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Many have commented on the low status of the speciality and the unsympathetic attitude and lack of respect shown by other professions and faculty members, especially physicians and surgeons. For example, Merton et al (1956) found that medical students ranked psychiatry seventh out of seven specialities. Bruhn & Parsons (1964) charted the precipitous decline in the perception of psychiatry at six different points in the medical career: medical students saw psychiatrists as confused thinkers and emotionally unstable often as abnormal as their patients. Furnham (1986), who studied 449 London students, found that psychiatry, compared with eight other specialities, was given the most pejorative scores on 26/50 items it was considered the most ineffective, unscientific and conceptually the weakest speciality. This echoes the public stigma of mental illness (e.g. Dean, 1996): psychiatrists run the gauntlet of the antipsychiatry bias of relatives, friends and the public. Dietz (1977) detailed the antipsychiatric influences of a generation of social research, which socially and legally discredited the profession.
Adverse financial terms have been suggested as a deterrent. There is concern about the financial effects of the College's decisions about higher psychiatric training under the Calman reforms (Double, 1998; McCallum et al, 1998; Shah, 1998). The relative earnings of consultants, however, will probably have more influence on recruitment.
On the other hand, many doctors enter psychiatry because of a personal concern for the mentally ill. They may have family members with psychiatric disorder. They may have personal experience of it. It is often supposed that psychiatrists are more vulnerable, but the objective evidence shows little difference (if any) compared with other specialities (Mowbray & Davies, 1971; Mowbray et al, 1990; Zeldow & Daugherty, 1991).
Social background, personality, attitudes and aptitude are important. Eagle & Marcos (1980) found that psychiatry attracted students from a lower social class, from cities, more often single and politically liberal. Walton and his colleagues (1963, 1964, 1966, 1969) found that psychiatry's constituency was a group of students who were more reflective and responsive to abstract ideas, liked complexity and were tolerant of ambiguity. Others have emphasised non-authoritarian attitudes, open-mindedness, greater interest in theoretical issues and social welfare and a preference for aesthetic values (e.g. Pasnau & Bayley, 1971).
Notwithstanding the stigma, psychiatry is an important and interesting part of medicine, appealing to curiosity and interest in emotions and actions (BMJ, 1973). In the study of Scher et al (1983) mentioned above, some students appreciated its holistic approach and the opportunity to know patients in depth. They enjoyed the breadth of the field and its interactions with other disciplines. Recent neuroscientific findings promised rapid advances.
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THE INFLUENCE OF THE MEDICAL SCHOOL |
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Parker (1958) noted an antagonism of medical students to psychiatry and called for education emphasising psychosocial functioning and relating symptoms to the wider context of the patient's life. This was followed by Sir Denis Hill's article (1960) on whole patient medicine:
Most of medical education would seem almost expressly designed to shield the student from awareness of the patient as an individual.
He advocated preclinical teaching of psychology and sociology. The same points were made eloquently by Iago Galdston (1968), who criticised the dismemberment of man, who needs to be understood holistically, ecologically and existentially. The biological bias of medical education was demonstrated by a videotape study (Silverman et al, 1983): two-thirds of Boston medical students failed to list a single social or psychological item as being relevant to the investigation of a man with chest pain and a woman with abdominal pain. These early papers set the scene for a more effective presentation of psychiatry to the medical student.
Historically, the speciality has reacted to the recruitment problem by focusing on the undergraduate curriculum. Much of the literature deals with this. This resulted in a range of ideas for improving the presentation of psychiatry:
There are data comparing the success of different medical schools in motivating students to enter psychiatric training. In the USA, medical schools with the strongest academic departments had the best recruitment (Nielsen, 1979; Sierles, 1982). In Britain, we have the Brook (1961-1970) and Parkhouse (1974-1980) data, which are summarised in Table 4. In 1976, Brook reported the medical school training of 531 psychiatrists who qualified between 1961 and 1970, and arrived at percentages for each medical school; these were extended and revised in a later paper (Brook, 1983). The Parkhouse surveys (Parkhouse & McLaughlin, 1976; Parkhouse & Palmer, 1977, 1979; Parkhouse et al, 1981a,b; 1983; Faragher et al, 1980; Parkhouse, 1983) asked graduates in their second pre-registration post about their career choices. On examining Table 4 it is obviously necessary to span several years before reaching any conclusions Oxford, Leeds, Glasgow and Leicester can single out years when they recruited 8-11% of medical students, but these were isolated triumphs. One decade may contrast with another; for example, Middlesex, whose recruitment was two standard deviations above the mean in 1961-1965, was below average in 1975-1980. In the Brook data, University College Hospital was the only medical school with recruitment more than two standard deviations above the mean in both quinquennia. In the Parkhouse series, the only medical school that stands out is St George's, which achieved 15% in 1979 (almost three standard deviations above the mean) and an average of 7.4% over the 7-year period. When one compares these figures with St Thomas' or Westminster, the conclusion must be that medical schools can (exceptionally) influence recruitment. Data of this kind have not been available for nearly 20 years but are re-emerging. Dr Goldacre and colleagues will be following up Dr Parkhouse's cohorts of 1974, 1977, 1980 and 1983 and are starting new cohorts for 1993 and 1996 (Lambert et al, 1996a,b).
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One should remember that peak interest in American psychiatry was reached in the 1950s and 1960s, when psychiatry had only a minor role in the curriculum (Weissman & Bashook, 1991). Low levels of recruitment have persisted in spite of a great increase in psychiatry's share of the curriculum time, the introduction of excellent teaching ideas and the establishment of chairs in almost all medical schools.
Student opinion is unstable in the short and the long term. There are great differences between career goals at medical school entry, intentions before and after the psychiatry module, at qualification, after the pre-registration year and when the final decision is made (Held & Zimet, 1975; Matteson & Smith, 1977; Egerton, 1983). Some have found that an initial interest in psychiatry falls steeply during the curriculum (Light, 1975; Zimet & Held, 1975; Pardes, 1982). But Paiva et al (1982) found a drift from other specialities into psychiatry more than any other speciality. There is some evidence that preference for psychiatry is more enduring than other specialities (Kritzer & Zimet, 1967).
Student preferences are a poor predictor of eventual career choice. Last & Stanley (1968) found that two-thirds changed their minds after leaving the medical school. Mowbray et al (1990) found that 65% chose psychiatry after graduation. Three studies are particularly informative:
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THE PRE-REGISTRATION YEAR |
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IMPROVING RECRUITMENT |
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If there is a will to raise recruitment, the College should analyse the pathway to a psychiatry career, including the nodal experiences and filters that determine a career choice in psychiatry (Table 5).
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The present data leave many uncertainties, but this brief review suggests that there may be more scope for improving recruitment by influencing the intake of medical students than by focusing on undergraduate teaching. Introducing more pre-registration house officer posts could be tried, preferably with prospective monitoring of its effect. Later career influences seem paramount why graduates chose psychiatry after the pre-registration year, and the attrition of trainees and consultants.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication January 12, 2000. Revision received October 15, 2001. Accepted for publication October 16, 2001.
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