In light of recent events with coronavirus, the national burden on mental health services is only set to rise over the coming few years — could finding a solution to the psychiatry recruitment problem help us cope? A medical student’s take on this increasingly concerning and important issue.
The early months of 2020 has seen the world gripped by the Coronavirus (COVID-19) pandemic. At a time when the focus is (very rightly) on frontline acute medicine, it’s impossible to ignore the fact that other medical and surgical specialties will struggle to continue providing a specialist service to their patients.
In psychiatry, there is likely to be a significant backlog of routine appointments, assessments and reviews once some normality resumes. Furthermore, with anxiety and bereavement becoming increasingly prevalent as a result of this pandemic, the demand for mental health services will most likely escalate. With a shortage of psychiatrists already compounding this issue, how will our mental health service cope? This blog is a student’s perspective on why we have a shortage of psychiatrists in the UK and will consider potential solutions to address this problem.
Applying for medical school is a long and exhausting process. After a gruelling 12ish-month medical school application cycle, (which includes at least one — and frequently two — admissions exams, multiple work experience placements in different healthcare settings and, for the lucky, several interviews) it is understandable that successful medical school applicants desire to make the best use of their degree upon graduation. And for some, a future in psychiatry seems to be at complete odds with how they envisage their future career.
Why? In a nutshell, because many medical students don’t get enough positive exposure to the most exciting areas of psychiatry whilst in medical school.
At the start of October 2019, the BBC reported an article on how ‘psychiatrist vacancies ‘threaten’ NHS transformation.’ Within it, they wrote that nearly one in 10 consultant posts is vacant, ‘up from 1 in 20 in 2013.’
They also quoted the dean of the Royal College of Psychiatrists, Dr Kate Lovett, as saying “Medical students just don’t seem to be attracted to work in mental health […] It’s not seen as a prestigious area to go into.”
With this article prompting discussion amongst my peers as to why so few of us are excited by the prospect of becoming psychiatrists, I thought now would be a good time to unpick some of those key reasons.
So why aren’t we choosing psychiatry?
Psychiatry is considered a challenging and daunting career by many of my peers.
There is a widely-held stereotype that there is little job satisfaction and many of the conditions encountered are far too complex to wrap our heads around, owing to some psychiatric disorders having poorly understood, complex causes.
Furthermore, some consider psychiatry to be relatively isolated from many other medical and surgical specialties — they often have separate units with little cross-specialty care. This is unappealing to students who have spent so long studying general medicine and surgery, as many would wish to employ more of this knowledge directly.
However, I believe the core cause is still rooted in an archaic — and now nearly totally incorrect — stigma around the actual role of a psychiatrist… Distinct and fiercely academic doctors who must rely solely on experienced and unique intuition rather than the usual clear-cut diagnostic tests seen in other specialties to treat their patients.
Whilst steps are being taken to address these, such as including more psychiatry in the curriculum at medical school, personally, I don’t think enough is being done to convince medical students that this isn’t accurate.
So, what IS being done to address this currently?
Psychiatry is currently considered a ‘hard to fill’ training programme by the NHS. Trainees in core psychiatric training and higher-level training are paid a small flexible pay premium to financially incentivise them to pursue the specialty. Promoting the specialty in this way would seem to also go hand-in-hand with the career providing greater job security as well. Whilst certainly these aren’t unhelpful incentives, there are reasons that neither of these are fully satisfactory reasons for pursuing a career.
To address the former, if doctors were primarily incentivised by money, they quite frankly probably would not have become doctors in the first place. Instead, they would have used their strong A-Level grades to make a bid for a more lucrative career. As such, pay premia may strengthen one’s resolve to pursue a career in psychiatry once already interested in the field, but would not likely in and of itself help to recruit more trainees to the specialty.
When it comes to job security, most medical students and junior doctors are relatively immune to the idea of competition, having faced around 1/10 odds of getting into medical school in the first place and then having to compete for where you want to initially train immediately after medical school. The prospect of job security is appealing, but not typically an immediate issue, and again, is not enough to attract individuals to the specialty in the first place.
Personally, I feel only one idea implemented thus far has the power to effect change, and that is by increasing the amount of psychiatry we are exposed to and taught within the curriculum whilst we are still training. Only by actually seeing the tremendous role psychiatrists play in patients’ lives and by dispelling the myths of therapeutic options being limited and ineffective will real change begin to happen.
So how else can we change the way we make psychiatry appealing to students?
In my opinion, recruiting students into psychiatry should centre upon the innate attractions of the job. I recently had a conversation with one of my peers, who indicated a desire to pursue a career in liaison psychiatry — a branch of psychiatry which involves psychiatrists working in general hospitals e.g. in A&E departments.
When we discussed this further, it transpired that the decision stemmed from the simple fact that he had really enjoyed his 5-week clinical placement in the specialty during his 4th year of medical school. This is a prime example of exactly why an emphasis should be placed on promoting the positive aspects of a career in psychiatry career itself, rather than any extrinsic motivators.
Such positive aspects include a chance to tackle an increasingly prevalent health burden on the national service through working with the development and implementation of novel treatments. For example, research around Ketamine as a therapeutic agent for treatment-resistant depression may offer the potential to revolutionise the treatment of a previously notoriously difficult-to-treat disorder. Our understanding of the mechanisms of complex psychiatric disorders such as schizophrenia is also ever increasing, and this is very exciting for much-needed future treatment options. Teaching students about these developments from early in medical school will encourage them to consider the specialty.
So, what are my pragmatic, potential solutions?
There have already been some fantastic initiatives launched by the Royal College of Psychiatrists and medical schools. One of the most exciting, in my opinion, is ‘Pathfinder,’ which allows students to connect with psychiatrists and receive mentoring, journal subscriptions and access to conferences, alongside many other benefits.
However, I believe that more can be done. It is important to target medical students that would previously not have considered psychiatry as a career as well.
In my opinion, the best way to do this, is to expose pre-clinical medical students to the career from first year. Leading academic psychiatrists should be encouraged to deliver guest lectures to pre-clinical students to talk about their careers and their research. Connecting different medical schools’ psychiatry societies regularly through social media should also be encouraged, so that outstanding events can be shared on a regional and national level. An interesting article was written on the value of these student-led societies and similarly argued that they are have enormous potential to foster interest in psychiatry.
I believe that all medical schools should have well-advertised schemes, encouraging students to engage with psychiatry research at both a laboratory and clinical level. Blogs such as Inspire the Mind are also useful to my peers and I — only a few months ago, Professor Kamaldeep Bhui CBE wrote a thought-provoking blog shedding light on the true and practical role of a psychiatrist. Perhaps, a blog competition run by different psychiatry departments is a way to allow students to dip their toe into engaging with psychiatry. Promoting regional essay competitions, which encourage students to engage with modern psychiatric literature is another way to develop interest.
Most importantly, psychiatrists themselves must try to engage positively with the medical students on their attachments — it is those experiences that are most formative in how we choose our specialties in the future. After all, psychiatrists are the best ambassadors for their discipline.
And we will need more psychiatrists than ever, to deal with the long-term consequences of this epidemic.
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