Sunday, 17 March 2013

Why Don't Medical Students Choose Psychiatry?

In this month's issue of the British Journal of Psychiatry, Goldacre et al discuss psychiatric recruitment in their paper 'Choice and rejection of psychiatry as a career: Surveys of UK medical graduates from 1974 to 2009'

Recruitment has been a sore point for the Royal College over the last few years with numbers
of foundation applications failing
to meet the number of available posts for core training. This has obvious implications for both the quality of candidates applying for a less competitive post and on the sheer number of psychiatrists available to meet demands. It also raises some important questions. Have such low recruitment levels always been present? Why is psychiatry relatively unpopular amongst medical students? And what, if anything, can be done about it?

Goldman et al analysed the data from recruitment questionairres given to newly qualified doctors from all UK medical schools for 12 years between 1974 and 2009. This amounted to responses from 33,974 doctors. The results show that 4-5% of doctors listed psychiatry as their first choice one, three and five years after graduation and that this remained largely stable over the 35 year period assessed. As noted by Davies, this is in contrast to the perceived threat of recent decline in graduate applications. Actually it seems psychiatry's popularity (for the last 35 years at least) has always been pretty low. So why is this the case?

Well the paper also included the factors influencing career choice (reasons given for choosing or rejecting psychiatry) and compared them with other specialities. What caught my eye was that job content was by far the commonest reason for not pursuing psychiatry at 71.7%  and this was significantly higher compared to 33.3% in other specialities.

The kinds of statements the authors classed as 'job content' are as follows:

 In addition, Goldacre et al state 
It seems likely that views about psychiatry may be more polarised than those for other specialties... Another UK study of doctors who initially chose psychiatry but then pursued a different career found that lack of respect among peers and the public, perceived threats of violence from patients, lack of resources and low morale were dissuading factors. A survey of Australian medical students found that the least attractive aspects of psychiatry included its lack of prestige and ‘perceived absence of a scientific foundation'
Having recently volunteered on the psychiatry stall at Manchester's medical careers fair, this certainly seems to reflect the concerns of the medical students who attended, whether seriously considering a career in psychiatry or not.

Looking at the above criteria, there seem to be at least three things going on here. The first is simply that psychiatry will not suit all students. There are certain aspects that will never change, such as the nature of patients' illnesses and for some, this just doesn't suit. In other words there is nothing inherently wrong with psychiatry 'its just not for me' (I can't stand gastroenterology, for example). 

The second is that many students have grave misconceptions about the nature of mental illness and psychiatry. Examples include 'psychiatrists don't make people better', 'mental illness isn't a real illness', 'most psychiatric patients are violent' and 'psychiatry is for doctors who aren't clever enough to do real medicine'. I have blogged about some of these myths before, so won't justify them here. The point is that it seems part of the reason for low recruitment rates is based on medical students' ill informed beliefs about the profession. It is therefore in the interest of medical schools and psychiatry to promote an honest and informed perspective of the specialty and of mental illness devoid of stigma and myths. 

Lastly, students may have accurate beliefs about the limitations of psychiatry which will lead them to other specialties. We should consider the areas of psychiatry that need to be improved or at least acknowledged.  For me the big issue is its scientific status. As I wrote in my last post, psychiatry doesn't have a unified theory of mental illness do guide its understanding. We don't yet understand how the mind emerges from the brain, let alone what happens when it goes wrong. This can make psychiatry seem a bit wooly, abstract or a soft science, despite its rigorous use of an evidenced research, as with the rest of medicine.

However, I would argue this is not the problem or necessarily the fault of psychiatry. The complexity of the nature of mind far outweighs the problems of describing the physiology of the heart for example. If psychiatrists are explicit about the conceptual and epistemological limitations of their speciality, working within these boundaries, this is good science, even if it is in what Kuhn might term the 'prescience' phase. To me, psychiatry should accept and be open about the fact it is, in some ways, not as advanced in its field simply because its field is more complex. 

The issue is when psychiatry utilises paradigms that are conceptually and methodologically floored, spouting them as successful explanatory models. Historically, of note are the (now rejected) paradigms of psychoanalysis, behaviourism and biological reductionism. Even relatively contemporary theories, such as the biopsychosocial model and pluralism provide only a partial explanation of mental illness. This should not be a put-off however. With the advances in psychology, psychiatry, cognitive neuroscience and philosophy of mind, knowledge of the mind and its discontents is progressing rapidly. The potential role of neural networks, systems theory, neural imaging, embodied cognition, metacognition and perceptual control theory are just a few areas to keep your eye one. This makes psychiatry, for me at least, by far the most fascinating and appealing specialty in medicine. 

PS Medical student or not I'd be keen to get your feedback on how you view psychiatry and mental illness.

Goldacre, M. J., Fazel, S., Smith, F., & Lambert, T. (2013). Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009. The British Journal of Psychiatry202(3), 228-234.

Davies, T. (2013). Recruitment into psychiatry: quantitative myths and qualitative challenges. The British Journal of Psychiatry202(3), 163-165.


  1. The CNS drug pipeline has dried up....that might be a factor...who wants to be writing the same old scrips for the same old neuroleptic, mood stabilizer and antidepressant combo in 30 yrs time?

  2. I'm interested in psych, but patient violence is a concerning factor for me.

    Many psychiatrists downplay the possibility of violent patients, but I've found many studies that show psychiatrists are more likely to be attacked by patients than other physicians, 40-50% of psych residents have been attacked in the previous year, and a psychiatrist is murdered every 2 years in the U.S. When's the last time a patient killed a peds, rads, or anesthesia doc? Harassment, threats, and stalking are probably much higher in psych too. I don't think specialists in other fields would be too concerned if their home address was readily found on the internet.

    What are your thoughts?

    1. Without a link to the paper I cannot really comment and I haven't read the literature so can only speculate.

      From my limited experience of psych and talking to psychiatrists, violence seems to be something of a rarity. The numbers you quote seem excessively high. Since psych encompasses substance abuse and psychopathy I would imagine this may bump up violence but this is only a small proportion of mentally ill.

      I would suggest getting as much psych experience as you can and see for yourself.And read around the literature as broadly as possible, this may just be a rogue paper.

      I have written about the common misconception of the mentally ill being violent here, using the commonly used example of schizophrenia.

      As an aside I would be interested to know how the rates of violence to doctors compares between psych and and A&E

    2. The recent news about the Batman movie shooter threatening his psychiatrist is pretty scary. I can't imagine it will make psych more popular. Here are some studies with hard numbers:

      Although their overall contribution to violence in society is relatively small (1, 2), individuals with severe mental illness are more likely to engage in aggressive and assaultive behavior than people in the general population (3–9). Thus, violence among the mentally ill constitutes a serious public safety concern. Particularly vulnerable are the mental health treatment providers who work with these violent patients. Among clinicians, violence toward psychiatrists is common and is an important issue (10–12); more than a third of psychiatrists have been assaulted by a patient at least once (10, 13). The risk of violent victimization is greater in clinicians with less experience (11). Reports estimate that 72% to 96% of psychiatric residents have been verbally threatened (12, 14–16), and 36% to 56% have experienced physical assaults (12, 14–18).

      "The annual rate of nonfatal violent crime for all occupations between 1993 and 1999 was 12.6 per 1000 workers.1 For physicians, the rate was 16.2. The rate for nurses was 21.9 (80% of nurses were subject to violent crime during their career). For psychiatrists, the rate was 68.2 per 1000. For custodial staff, the rate was 69 per 1000. The rate for other mental health workers was 40.7. Of psychiatrists responding to surveys, the average rate during their careers was 40%.
      Surveys of psychiatric residents found an assault rate ranging from 19% to 64%; rates of repeated assaults ranged from 10% to 31%. The assault rate was 20% among surgical residents, and 16% to 40% among internal medicine residents. Compared with the nonfatal crime rate for all workers, health care professionals—especially mental health workers—are at heightened risk for becoming victims of violence."

      We performed a review of the international literature, Royal College of Psychiatrists guidelines and Irish legislation concerning psychiatric trainees and their experience of violence. Physical violence in the workplace was reported by 16% of trainees in Ireland and 67% of specialist registrars in the UK; 72% of trainees in Belgium reported verbal violence.

  3. The term ‘psychiatry’ was first used 200 years ago in 1808, in a 188-page paper by Johann Christian Reil. He argued for the urgent creation of a medical specialty to be called ‘psychiatry’, and contended that only the very best physicians had the skills to join it.

  4. Thank you for that amazing article. It's a great reading to get to know the basic stuff about psychiatry. And it helps people get to know better this science.

  5. This comment has been removed by a blog administrator.

  6. "The issue is when psychiatry utilises paradigms that are conceptually and methodologically floored, spouting them as successful explanatory models."

    "The complexity of the nature of mind far outweighs the problems of describing the physiology of the heart for example"

    As an undergrad. studying a biological science, I have been taught about the methodologies of techniques and that there are always limitations and pitfalls for these methods, no matter how well some of them have worked. So if there are such limitations and issues with investigating about the physiological system with techniques that are flawed, I could imagine that with a science that is so complex in nature like psychiatry, for there to be yet a 'successful' and widely acceptable method used at all, which I think contributes to the slow-moving pace of the field and may be another factor why students wouldn't choose this as their major.

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