I have not submitted anything in a while so I thought what the hell. Monday past was the deadline for a psychiatry essay prize, a prize I heard about on Sunday. So I quickly typed this up and submitted it. Mostly to cheese off Rebecca.
David Simon’s newest televised endeavor chronicles the aftermath of Hurricane Katrina and the neglect of the people of New Orleans. In one episode Creighton Bernette, an obstreperous, and particularly patriotic, local laments his city’s neglect and lack of financial aid on ‘the Youtube’. Much to the chagrin of psychiatrists in this country mental healthcare seems similarly neglected. However, one unique factor that must exasperate those in the profession is not lack of funding, a ubiquitous problem in the NHS, but the lack of students choosing psychiatry at a postgraduate level. Why is this? With over 85% of trainees entering the profession from overseas, Max Pemberton recently described the state of affairs as a ‘crisis’ and that ‘serious questions need to be asked as to why UK medical graduates are turning away from psychiatry.’ In 2006 an article by HG El-Sayeh et al used the same word ‘crisis’ when they outlined ‘how to win the hearts and minds of students in psychiatry’. The question remains, why is this? Why do medical students not have the same zeal for psychiatry as so many do for general surgery or paediatrics? Of all the specialties, why is psychiatry often cited as the least popular? What changes between sixth form, when psychiatry is such an appealing career to students, and postgraduate life? Goldacre et al suggest a blatant truism: five years of medical school.
The most obvious experience to reflect on as a medical student with regards to psychiatry would be my recent four week stint in a district general hospital in Manchester. Fourth year of the University of Manchester programme seamlessly slips psychiatry into one of the semesters, along with orthopaedics, rheumatology and neurology. However, Manchester students begin attending GPs regularly in third year, and even before that. As a University of St Andrews graduate I had placements in primary care as early as my first year of study. Literature suggests that in a single year one in four people suffer from a psychiatric disorder. A plethora of conditions varying in their severity and affecting individuals in different ways. The majority of those who present as patients are seen by GPs. Depression is particularly common in primary care, so common that some worry GPs may be underdiagnosing it.Whatever the prevalence and whatever the disorder medical students see many psychiatric presentations early in their undergraduate lives in primary care. Medical students’ experiences are subjective but reflecting on the times I have seen psychiatric presentations in the community it has usually been with a GP bemoaning the next patient’s on the list depression. Contradictory, since we view general practice and psychiatry as two of the most holistic specialties. Sadly this negative view of psychiatry in primary care does not seem to be limited to the University of Manchester.
Even before we meet any psychiatrists our experiences in general practice have moulded preconceptions. The little early teaching received on clinical psychiatry in lecture theatres or problem based learning compounds the problem. It is difficult to be engaged or discuss cases patients with little knowledge of the subject matter. Excessive teaching instead on psychological models alienates students and fails to nurture the interest a substantial proportion of students have before undergraduate study. This needs to be reversed. Psychiatry is a colourful and unique specialty with bizarre conditions to captivate first and second year medical students. A clear opportunity is being missed. If GPs often seem underwhelmed by psychiatry, hospital medical staff too often seem cynical. As soon as students enter the hospital environment there is this schism between those who want to be physicians or those who are budding surgeons, and students seem to approach placements with respective gusto. I am being a bit facetious making a statement like that – after all, half of graduates end up in general practice! Nonetheless, it is odd psychiatry is so rarely mentioned. Much like in that episode of Mad Men where Joan Holloway’s husband Greg settles for a job in psychiatry after failing at what is perceived as the more legitimate career of general surgery, stereotypical and condescending views of psychiatry persist in medical practice today.
Eventually students are given an opportunity to form opinions of their own on psychiatry. The fickle nature of the medical degree provides students with varying experiences but whatever the specialty students look for the same aspects. These include a structured set of learning objectives at the beginning of a placement; a well-organized timetable; ample opportunity to take histories on the ward or see patients in clinic; some knowledge of the undergraduate curriculum by those giving formal teaching sessions; encouraged active participation in ward rounds; both clinical and clerical staff being alerted to the presence of students; courtesy shown by these individuals. My own experience of psychiatry was a positive one. Unfortunately it was also only four weeks.Tomorrow’s Doctors dictates the curriculum must consist of a minimum of 10% of course time spent on student selected components (SSC), a rational effort to allow ‘students to exercise choice in areas of interest’. Nevertheless, four weeks of psychiatry seems too short, and it begs to be asked how many students choose psychiatry as a SSC, and in view of the preconceptions listed above what reason is there for students to choose psychiatry as an SSC?
It is easy to label poor old psychiatry as the pariah of medical specialties but it has some shortcomings other specialties do not. Consultations are much longer, past psychiatric and social histories more myriad, and so doctors are understandably more reluctant to let students get a more ‘hands on’ experience in clinics. My aspirations to pursue paediatrics is at least part attributable to the opportunities I got to clerk in numerous children myself. I never felt similarly part of the mental healthcare team. Taking histories on a psychiatric ward is also more difficult than on a surgical or medical ward. However, when I did get to take histories they were the most challenging and interesting patients I have spoken to as student. A lot of psychiatry placements are also spent in the community. This exaggerates any poor administration. The greatest frustration as a student is due to cancelled tutorials, lectures or clinics. Shadowing different individuals in different places every day also makes continuity of teaching difficult to attain.
So what can be done? Students want to be involved on placements and see patients themselves. There may be limited scope for this in some situations in psychiatry but active involvement on ward rounds and clinics can lead to more engaged and interested students. Challenging students by asking them to take histories or present patients will do the same. Changes to teaching early in the degree with more of a focus on clinical psychiatry can make the specialty more exciting from the outlook. Not everyone will go into psychiatry but undergraduate experiences in the specialty can at least be enjoyable ones. More students can arrive on their first day of psychiatry expecting to enjoy the placement instead of resenting it. Combined with longer placements tomorrow’s doctors will inevitably be more informed and enthusiastic about mental health, and just maybe they will be more likely to dedicate a career to this unique specialty.
 Treme, At the Foot of Canal Street (2010)
 N Hawkes et al, Health manifestos, BMJ, 340 (2010) 892-897
 HG El-Sayeh et al, How to win the hearts and minds of students in psychiatry, Advances in Psychiatric Treatment, 12 (2006) 182-192
 Rajagopal et al, Psychiatry as a career choice compared with other specialties: a survey of medical students, The Psychiatrist, 28 (2004) 444-446
 Maidment et al, Carry on shrinking: career intentions and attitudes to psychiatry of prospective medical students, The Psychiatrist, 27 (2003) 30-32
 Goldacre et al, Career choices for psychiatry: national surveys of graduates of 1974-2000 from UK medical schools, British Journal of Psychiatry, 186 (2005) 158-164
 R Jenkins & S Griffiths, Indicators for Mental Health in the population (ed.), (1991) The Stationary Office
 S Gilbody et al, Should we screen for depression?, 332 (2006) 1027-1030
 RP Dixon et al, Medical students’ attitudes to psychiatric illness in primary care, Medical Education, 42 (2008) 1080-1087
 N Manek & K Allen, Changes to GP training, BMJ Careers (2009) http://careers.bmj.com/careers/advice/view-article.html?id=20000259#ref8
 Mad Men, The Gypsy & The Hobo (2009)
 General Medical Council, Tomorrow’s Doctors, London: General Medical Council (2009)
PS Phil, there is no ‘Medicine’ category. Maybe this is a good thing…