PsychiatryBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7071.2 (Published 14 December 1996) Cite this as: BMJ 1996;313:S2-7071
- Anne Dean
- Head of Postgraduate Educational Services, Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG (tel: 0171 235 2351)
Despite rising demand, recruitment to psychiatry is constant: something that its royal college would like to address. Anne Dean analyses the characteristics necessary for an successful career in the specialtyg
There are probably as many public misconceptions of what psychiatrists actually do as there are about the training needed to become one. The cliched picture of the bearded man, nodding sagely by a patient flat out on the couch, is rather difficult to shift. Sometimes psychiatrists are confused with psychologists or counsellors or, worse still, regarded as eccentric therapists without proper medical qualifications who practise their spurious brand of “treatment” on a gullible public. In fact, psychiatry usually attracts committed individuals with a desire to make a positive mark in a specialty which can be one of the most stimulating, interesting, and rewarding in medicine.
Like all medical specialists, psychiatrists are doctors first and specialists second. Thus, psychiatry is emphatically a medical career, and shares with other medical disciplines the authority to prescribe drugs and recommend treatments. Through work in the area of evidence based medicine, together with the reliability of its outcome measures, psychiatry has proved that it is as clinically effective as any other medical specialty. Additionally, recent developments in neuroimaging and psychiatric genetics suggest that there will be exciting and far reaching developments in our understanding of the biological basis of mental disorders over the next 20 years.
The specialty is certainly not without its problems, and recruitment and retention have been difficult recently, despite general practice also being less popular. Reports of low morale in the specialty, an increasing workload for both trainees and consultants, and a lack of resources, particularly in inner city mental health services, may be some of the reasons for this. Other medical specialties face similar problems, but psychiatry also has to cope with the bad press that inevitably follows local tragedies concerning psychiatric patients, as well as the stigma associated with mental illness.
All is not gloom: the Royal College of Psychiatrists is aware of these problems and is working on their resolution. Several projects addressing salient issues are underway, which include plans to improve psychiatric provision for ethnic minority groups and a joint recruitment initiative with the NHS Executive.
A career in psychiatry has a great deal to offer. Doctors working in this area develop skills which help people to cope with their mental health problems, enabling them to make progress towards a solution after other help has failed. People with mental illness are often extremely unhappy and difficult to reach; may feel cut off from the rest of the world and find it almost impossible to have trust or confidence in anyone. Their psychiatrist can be the one person who can make a difference and can give hope at the most despairing times. While cures are often difficult to effect, psychiatrists can make an enormous contribution to improving the quality of life of their patients, reducing their symptoms and distress, and making an impact on their social conditions. A good psychiatrist must find a workable balance between the toughness necessary to face up to difficult and even threatening behaviour on a regular basis, while at the same time retaining sensitivity, compassion, and first rate interpersonal skills. Such a career is by no means easy, but the rewards can be great.
Because of the nature of their work, psychiatrists draw heavily on the social sciences, in particular sociology and psychology. This makes the specialty attractive to those of an inquisitive and thoughtful disposition. An innovative and creative mind is required, together with patience and well developed problem solving skills. A leaning towards detective work can be helpful, since piecing together the clues to a (hopefully) satisfying end is a regular task.
Psychiatry offers the opportunity for doctors to try to understand very complicated phenomena, for example, the symptoms of psychotic illnesses like schizophrenia. Trying to make sense of the seemingly incomprehensible is intellectually challenging; patience is also a crucial requirement. Some complex questions have no straightforward answers, so coping with uncertainty is an important skill, which can be developed over time. Psychiatry is a particularly appropriate choice for doctors who enjoy listening and learning about the infinite variety of human behaviour, close working relationships with patients, and for whom uncertainty is a challenge rather than an irritant. A well developed sense of humour is a pre-requisite.
British psychiatric training schemes are some of the most intensive and effective on offer anywhere. Standards are closely monitored, and trainees enjoy close links with the college through its Collegiate Trainees' Committee where they can contribute to educational policy making, training strategies, the administration of the membership examination (MRCPsych), and training post approval visits. Psychiatric trainees can also make a large impact on their training at a local level through trainees' committees. General professional training in psychiatry lasts for three years, followed by three years in higher training, which leads to the Certificate for the Completion of Specialist Training (CCST). In psychiatry, dual accreditation can be achieved in different subspecialties by extending the period of higher training.
Although Calman has made an impact, psychiatric training schemes had less change in the structure than with some other specialties. The new specialist registrar grade has now been implemented, and prospects for progression towards an early consultant appointment are excellent. The Calman changes have increased the emphasis on rigorous assessment and monitoring of standards, and this has led to better communications between trainers and trainees. The college has implemented an educational overview, including the introduction of definitions for an approved MRCPsych course, a core curriculum, and an ongoing desire to improve links with postgraduate deans and regional advisers.
The college insists on a substantial commitment from educational supervisors, including a one hour face to face session each week between the educational supervisor and the trainee. Until now the college's Central Approval Panel monitored standards of basic training through its regular inspection scheme. This has been reinforced by Record of In-Training Assessment (RITAs) introduced by regional postgraduate deaneries. The purpose of the weekly session is to provide a designated period of time which belongs exclusively to trainees and which is intended to be of direct benefit to them, and is quite separate from the general clinical supervision they receive. Among issues which might be covered include training issues and workload, some elementary instruction in counselling and psychotherapy, presentation techniques, advice on fostering good relationships with other disciplines, and pastoral/personal matters.
Personality and skills of a psychiatrist
One might argue that all doctors should have
Varied life experiences before entry to the specialty
Interests such as travel, theatre, music or the arts
Intellectual rigour combined with all round ability
An inquisitive and humane nature
A well developed sense of humour
Excellent communication and interpersonal skills
A calm, unflappable nature
Patience, tact, and the ability to work with uncertainty,
but such attributes are even more essential for psychiatrists.
In a specialty where there are often no easy answers, many patients must be managed for a very long time. Psychiatry is not for doctors who thrive on immediate results or the excitement of making a split second decision-although there may be occasions when this is necessary.
In many parts of the country psychiatric trainees often enjoy less onerous on call commitments than colleagues in other specialties. Emergencies do occur, but the frantic rush of, for example, surgical or accident and emergency rotas is rare.
Psychiatrists work in multidisciplinary teams with social workers, community psychiatric nurses, clinical psychologists, occupational therapists, and other health professionals. The specialty attracts as many women as men, and female psychiatrists are well represented at the top end of the profession. The nature of the work makes it particularly well suited to part time (flexible) trainees, and every effort is made to accommodate them with specially tailored flexible training programmes. Graduate recruitment into psychiatry from medical school remains constant: about 4% choose psychiatry as their career each year, though the proportion varies between medical schools. The college is currently reviewing its recruitment strategies in an effort to improve these numbers. In addition to local training days and workshops, college tutors may be given the responsibility for careers information for trainees. The college has also recently implemented an initiative to increase its profile on career issues, and to improve its dissemination of career information. A college representative already attends all careers fairs held in the London area, participating in question and answer sessions and providing current information on careers in the specialty. College regional advisers in psychiatry have been asked to identify a young, enthusiastic consultant willing to do this for their region.
This initiative is now well underway, and a review of all careers literature produced by the college is also being reviewed to ensure that an up to date and accurate picture of a psychiatric career is provided. Current careers literature includes two Question and Answer sheets, one aimed at school leavers and one at medical students; a careers flowchart; a paper setting out sample teaching and service commitments; another giving information on the structure of the NHS; and three articles offering different perspectives on life as a trainee psychiatrist. The updates for these articles are likely to be written by a woman, and/or an overseas doctor and a part time trainee.
Psychiatry is constantly evolving, genuinely forward looking, and offers would be psychiatrists excellent prospects for the future.