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
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.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'
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 Psychiatry, 202(3), 228-234.
Davies, T. (2013). Recruitment into psychiatry: quantitative myths and qualitative challenges. The British Journal of Psychiatry, 202(3), 163-165.