Recruitment

There is a crisis in recruitment in psychiatry. Psychiatry is the least popular clinical specialty among medical students, in both the UK and most countries worldwide (Reference Rajagopal, Rehill and GodfreyRajagopal 2004). Sixth-form students are often interested in a future career in psychiatry, but something changes during the medical school years (Reference Maidment, Livingston and KatonaMaidment 2003). Only 3–4% of medical graduates express an interest in psychiatry as a career at the end of training – half the number required to fill consultant posts (in the UK, recruitment from overseas masks poor local recruitment) (Reference Brockington and MumfordBrockington 2002; Reference Lambert, Goldacre and TurnerLambert 2003). However, the great variation in the numbers entering psychiatry from different medical schools shows that good teaching can influence recruitment (Reference Lambert, Goldacre and TurnerLambert 2003; Reference GhodseGhodse 2004; Reference Paddock, Farooq and SarkarPaddock 2013).

Attitudes to psychiatry significantly improve during teaching programmes (Reference Baxter, Singh and StandenBaxter 2001; Reference Glynn, Reilly and AvalosGlynn 2006), but interest typically wains thereafter: one study reported a fall in interest from 10–11% to 3–4% within 1 year (Reference Tharyan, John and TharyanTharyan 2008). Students’ exposure to non-psychiatric specialties in the final year and their focus on what they think they will need immediately after qualifying are likely reasons (Reference Baxter, Singh and StandenBaxter 2001). Fortunately, psychiatry has started to be included in the foundation years for new doctors, thus increasing exposure (Reference CareyCarey 2000), and with the recent steps to increase the number of these posts, we have a wonderful opportunity to rectify the problems in recruitment. Quality of teaching is an important ‘modifiable’ influence on recruitment, especially for those with neutral views beforehand (Reference Niedermier, Bornstein and BrandemihlNiedermier 2006). Positive attitudes are promoted by direct patient contact, encouragement from consultants and seeing patients respond well to treatment (Reference McParland, Noble and LivingstoneMcParland 2003; Reference Oakley and OyebodeOakley 2008). If more psychiatry could also be taught in the final undergraduate year, then recruitment might improve further (Reference Baxter, Singh and StandenBaxter 2001). However, the creation of the extra foundation posts in psychiatry is even better.

Yet, there is more to recruitment than just teaching. Unfortunately, criticism or ‘bashing’Footnote b of psychiatry by other specialties is common (Reference Ajaz, David and BrownAjaz 2016; Reference Baker, Wessely and OpenshawBaker 2016), which puts medical students off particular specialties (especially psychiatry), thus affecting recruitment (Reference Baker, Wessely and OpenshawBaker 2016). One of us (S. N. S.) has been ridiculed by other clinicians for being a psychiatrist: ‘Who would want to deal with “psychos” by choice?’ They have assumed that he entered psychiatry as a ‘last resort’, having failed in other medical fields, or ‘to have an easy life as it doesn't take much hard work or brain-power’. Psychiatrists are often perceived as unscientific, confused thinkers, emotionally unstable and ineffective (Reference Dubugras, Mari and dos SantosDubugras 2007; Reference Ajaz, David and BrownAjaz 2016). They are portrayed negatively in the media (Reference Dubugras, Mari and dos SantosDubugras 2007). All this has an impact on recruitment by influencing students’ perceptions of psychiatry as a career. It is seen as too slow moving with few clear results/improvements, and ultimately psychiatrists have low status due to lack of respect shown by other specialties (Reference Brockington and MumfordBrockington 2002; Reference Baker, Wessely and OpenshawBaker 2016).

A recent survey examining factors influencing career choices among a group of psychiatric trainees and medical students pointed to the powerful role (both positive and negative) of the consultant and role modelling (Reference Paddock, Farooq and SarkarPaddock 2013). Reference Shah, Brown, Eagles, Brown and EaglesShah et al (2011) also investigated factors influencing career choice among foundation trainees (Box 1). They found that the psychiatric rotation in the Foundation Programme could improve recruitment by giving trainees work experience in a field they might not otherwise have considered as a career. This in turn could increase the proportion who decided on psychiatry as their top choice of specialty.

Stereotyping and stigma

Challenging negative stereotypes about psychiatry is a huge motivator for us to create ‘ambassadors of psychiatry’ through our teaching. Stereotyping is an efficient way of structuring knowledge – it is an effective strategy that cuts the cognitive workload, thus reducing uncertainty related to any novel stimulus (Reference TownsendTownsend 1979). It therefore appeals to ‘strategic’ students (to whom we return later in this article).

Stigma in psychiatry is encountered in negative views not only about psychiatrists, but also about their patients. Some have suggested that ‘the rejecting voices of others may bring greater disadvantage than the primary condition itself’ (Reference Thornicroft, Rose and KassamThornicroft 2007). Unfortunately, stigma is very common and it has an immense impact on patients and a negative influence on recruitment. Stigma is not explicitly addressed in undergraduate teaching, yet we have a duty to tackle it. The problem is magnified by the difficulty of assessing stigma.

Reference ByrneByrne (2000) points out that stigma (like beauty) is in the eye of the beholder. Many people get their information about mental illness from the mass media. Psychiatric disorders, their treatments and those who provide them are all subject to overwhelmingly negative portrayals in the print and broadcast media (Reference EdneyEdney 2004; Reference Wahl and FriedmanWahl 2004, Reference Wahl, Hanrahan and Karl2007). Many studies have found a definite connection between negative media portrayals of mental illness and the public's negative attitudes towards people with mental health problems (Reference Coverdale, Nairn and ClaasenCoverdale 2002; Reference OlsteadOlstead, 2002). Reference WahlWahl (1995) found that this negative media influence also extended to healthcare professionals. A Mind survey found that half of the respondents said that the media coverage had a negative effect on their own mental health (Reference Baker and MacphersonBaker 2000), but more worryingly, Mind's 1996 survey on stigma (Reference Read and BakerRead 1996) revealed that 50% of people with mental illnesses felt discriminated against by medical services, and this theme has been commented on again recently (Reference Baker, Wessely and OpenshawBaker 2016). The impact of these stigmatising attitudes was further highlighted by Reference Thornicroft, Rose and KassamThornicroft (2007) and Reference Baker, Wessely and OpenshawBaker (2016) . If parity of esteem between physical and mental health is lacking within medicine, then how can we expect it to exist outside? The stigmatising of psychiatrists and the mentally ill stimulates stigma in society and could discourage patients with mental health problems from seeking help for both mental and physical ill health (Reference Baker, Wessely and OpenshawBaker 2016). Doctors with mental illness have high suicide rates due to denial and delays in seeking treatment because of the shame of stigma (Reference GrayGray 2002). Unfortunately, although attitudes appear to have improved in some areas more recently, there has not been enough improvement overall (Reference MindMind 2013; Reference Baker, Wessely and OpenshawBaker 2016).

Stigmatising attitudes develop in early childhood, so they are difficult to change. Increased knowledge and contact with mentally ill people challenge negative stereotypes, but one negative image can override the cumulative effects of many positive experiences (Reference ByrneByrne 2000). However, as Byrne stated, the starting point in tackling stigma is education, and there are a number of ways in which we can reduce stigma in our teaching of students and trainees. We should acknowledge and address stigma as a separate and important issue in its own right. Patients and carers should be involved in training healthcare professionals (Reference Walters, Raven and RosenthalWalters 2007). The more direct contact that students have with both patients and carers, the better. Patients’ narratives ‘normalise’ mental illness and allow patients to be seen as individuals. Students eventually learn that anyone can develop mental illness if there is enough stress, and this lowers the ‘them and us’ attitude (Reference GrayGray 2002). Home visits allow students to try to understand how a patient lives and behaves in their own environment, culture and context (Reference Walters, Raven and RosenthalWalters 2007; Reference Dogra, Anderson and EdwardsDogra 2008). Role-play in which students take on the part of patients can be a powerful experience that builds empathy and reduces stigma (Reference McNaughton, Ravitz and WadellMcNaughton 2008).

Reference SalterSalter (2003) recognised that the media are less interested in content, but rather in whether the information is interesting and sustains attention. So should we be playing the media at their own game, by making teaching interesting, but with positive images of mental illness and psychiatry (Reference EdneyEdney 2004)? In light of the growing use of social media and the internet, should we explicitly acknowledge the existence of stigma and prejudice in the media and use clips (both positive and negative) to encourage healthy discussion and debate in a safe environment? Should we not move with the times and make our teaching more relevant?

Ideal teaching practice

Role modelling, particularly of senior clinicians, is an important factor that determines career choice and attitudes, so we need to use this to our advantage (Reference Shah, Brown, Eagles, Brown and EaglesShah 2011; Reference Paddock, Farooq and SarkarPaddock 2013). We need to demonstrate not only what to do and how to do it, but also the right attitude. Ideal teaching practice should therefore counteract negative experiences, while building on positives. We need to be enthusiastic about teaching and try to create a relaxed, positive atmosphere with open questions and discussion based on interesting examples. Students might be matched with specific patients, to promote experiential learning. A ‘thinking aloud’ approach can aid decision-making and professionalism (Reference SkånérSkånér 2005; Reference Cross, Moore and MorrisCross 2006). Giving individualised feedback and also asking for feedback to adapt one's own teaching would continually enhance quality (Reference Sluijsmans, Brand-Gruwel and van MerrienboerSluijsmans 2003). A personal narrative explaining what it is like to live the life of a psychiatrist might be an effective way of improving recruitment, as the student or trainee could picture working in the profession themselves (Reference Hashmi, Talley and ParsaikHashmi 2014; Reference Berkhout, Helmich and TeunissenBerkhout 2015).

The essence of teaching ought to be to try to make students/trainees feel important (Fig. 1). Foster an environment conducive to learning by not causing students to feel that they are a burden, that their learning is interfering with patient care by intruding on privacy or encroaching on a clinician's time. Students/trainees need to be given achievable responsibilities to enable them to feel that they are contributing to patient care, and thus feel accountable and part of a team. Making juniors feel important motivates them to learn more than just how to pass assessments, by promoting deeper learning and professionalism.

FIG 1 Examples of how to make juniors feel important – a strategy for students and the first few weeks of foundation trainee placements (see online data supplement for references).

Assessments – limitations and solutions

Assessment motivates students to learn, but what should the real aim of teaching be – helping students to pass exams or enabling them to be better doctors/psychiatrists (to be competent and professional) (Reference Cantillon, Hutchinson and WoodCantillon 2006)? If we are merely aiming for higher pass rates, we are limited by the validity of assessment (i.e. whether a test predicts that someone will become a good doctor). There is often a balance between validity and reliability (Reference Sweet, Hutly and TaylorSweet 2003) and also between what is ideal and what is feasible (Reference Van der Vleuten, Schuwirth and DriessenVan der Vleuten 2012; Reference Hodges, Hollenberg and McNaughtonHodges 2014). Direct observation of students seeing real patients is valid, but not always practical, hence the use of simulated patients – actors trained to portray signs and symptoms (Reference Schuwirth and van der VleutenSchuwirth 2003; Reference DaveDave 2012). However, standardisation of simulation (Reference Sweet, Hutly and TaylorSweet 2003; Reference Cantillon, Hutchinson and WoodCantillon 2006) can still cause problems.

Miller's pyramid (Reference MillerMiller 1990) is a well-known framework for assessing clinical competence (Fig. 2). Reference NormanNorman (2005) has challenged the simplicity of this framework, and various authors have debated its usefulness: any single assessment (point measurement) implies a compromise on quality criteria, since one method can assess only a part of the pyramid (Reference NormanNorman 2005; Reference HodgesHodges 2006; Reference Van der Vleuten, Schuwirth and DriessenVan der Vleuten 2012). Furthermore, performance is highly context dependent (Reference Van der Vleuten and SchuwirthVan der Vleuten 2005), so any attempt at standardisation will only trivialise the assessment (Reference Norman, Van der Vleuten and De GraaffNorman 1991). A single method of assessment cannot cover all aspects of competencies of the layers of Miller's pyramid, so we need a blend of methods, including professional judgement (Reference Van der Vleuten and SchuwirthVan der Vleuten 2005).

FIG 2 Miller's pyramid amended to show that single assessments often result in a trade-off between reliability and validity. MCQs, multiple choice questions; OSCEs, objective structured clinical examinations; WPBAs, workplace-based assessments.

A competency is the ability to handle a complex professional task by integrating the relevant cognitive, psychomotor and affective skills (Reference Van der Vleuten and SchuwirthVan der Vleuten 2005). It involves knowledge, skills, problem-solving and attitudes (Reference Frank and DanoffFrank 2007). In medicine, it has been defined as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served’ (Reference Epstein and HundertEpstein 2002). Too much emphasis on competence-as-knowledge risks creating ‘hidden incompetence’ – knowledge-smart doctors who have poor interpersonal and technical skills (Reference MillerMiller 1990; Reference HodgesHodges 2006).

The psychometric discourse on assessing clinical competence converts human behaviours into numbers (Reference HodgesHodges 2013). There has been a tendency to break down competence into smaller units or stable, measurable ‘traits’ that are assessed separately, on an assumption that the sum of these parts can equate to competent performance in an integrated whole (Reference Van der Vleuten and SchuwirthVan der Vleuten 2005; Reference HodgesHodges 2013), but many have criticised this as ‘over-objectification’, ‘reductionism’ and ‘trivialisation’ (Reference HodgesHodges 2006; Reference Zibrowski, Singh and GoldszmidtZibrowski 2009; Reference Van der Vleuten, Schuwirth and DriessenVan der Vleuten 2012). Reliability is relevant at the level of individual assessment tools, but not when heterogeneous sources of information are combined (Reference HodgesHodges 2013). Should we then be going beyond the psychometric discourse and single assessments of competence? Figure 3 outlines strategies that might be used to optimise assessment.

FIG 3 Strategies to optimise assessment (see online data supplement for references).

Strategic learners

Assessment plays a dominant role in student learning, but it can have both intended and unintended consequences. For example, end-of-year exams, which rely on recall of factual information, can lead to cramming and only surface-level learning (Reference Newble and JaegerNewble 1983; Reference EpsteinEpstein 2007).

Strategic learners are common in medicine. They are motivated (externally) by exams/assessments and might overlook professional values. Given the sheer volume of factual information to process in order to become a doctor, students feel overloaded and their learning becomes strategic. This approach often continues into the post-graduate years. To take more interest or study a topic in depth might mean failing something else, so tight is the balance. Reference Kneale, Armstrong, Thompson and BrownKneale (1997) attributed this growing problem to the increasing anonymity that students feel as medical schools become ever larger. They attend only if they know it will be part of their assessment – i.e. if attendance registers are taken or if a senior figure is present. They prefer exams (i.e. surface learning for short-term recall) rather than continuous assessments (Reference Kneale, Armstrong, Thompson and BrownKneale 1997) and study only for the parts of the course that are assessed (Reference Wass, Van der Vleuten and ShatzerWass 2001). Cutting corners results in a lack of meaningful understanding or a change in attitude due to cognitive restructuring. Prejudices regarding psychiatric professionals and patients therefore remain.

Are we strategic teachers?

We can't help thinking that many of us might in fact be ‘strategic teachers’, such is the juggling act we find ourselves in. We face barriers to teaching, such as lack of time, resources, funding and recognition (Fig. 4). Are we in essence merely ‘good enough’ teachers, as opposed to good teachers? If so, what example is this setting our students and what impact is it having (Fig. 5)?

FIG 4 Strategic teachers – how do we fit teaching in? CPD, continuing professional development.

FIG 5 Potential negative effects of strategic teaching.

Making the most of the learning environment

The uniqueness of the psychiatric setting should be used to its best advantage (Reference Parsell and BlighParsell 2001; Reference Cantillon, Hutchinson and WoodCantillon 2006). Working within a multidisciplinary team and involving patients and carers/relatives enables students to understand different points of view. This is essential to becoming a psychiatrist (Reference Davies and McGuireDavies 2000). Arranging a mix between general versus specialised and in-patient versus community settings will give students the broadest view of psychiatry with which to make an informed career choice or develop sympathetic attitudes to the field (Reference GhodseGhodse 2004). Home visits are an effective way of reducing stigma towards patients (Reference Walters, Raven and RosenthalWalters 2007). Ward rounds can be made more useful by highlighting teaching points and giving students tasks to keep them active. Smaller groups enhance collaborative learning and team work (Reference Sweet, Hutly and TaylorSweet 2003; Reference Cantillon, Hutchinson and WoodCantillon 2006), and one-to-one teaching and feedback are tailored, adaptable and instil enthusiasm as well as enabling modelling (Reference Parsell and BlighParsell 2001; Reference Sweet, Hutly and TaylorSweet 2003; Reference Cantillon, Hutchinson and WoodCantillon 2006; Reference Cross, Moore and MorrisCross 2006). ‘Hot-seating’, allowing students to see patients alone in clinic before seeing them together, enables experiential learning (Reference KolbKolb 1984; Reference Kneale, Armstrong, Thompson and BrownKneale 1997). However, this is not always feasible, due to time constraints and shortage of rooms.

Their role in service provision might mean that foundation doctors have less flexibility to visit other services for a broader experience of psychiatry. Yet, it is essential to take a longer-term approach and to allow flexibility for a varied experience, as this ought to improve recruitment to, or at least a better understanding of, our field.

Teachers’ characteristics influence students’ learning and motivation. We were inspired by those who were enthusiastic and caring. Good teachers create an atmosphere in which students are motivated by intrinsic drives – identifying with and then modelling enthusiasm (Reference MarkertMarkert 2001). The literature points out that the characteristics of good clinical teachers broadly fall into two dimensions: Reference Beishuizen, Hof and van PuttenBeishuizen (2001) identifies them as the ability and personality dimensions, whereas Reference Sutkin, Wagner and HarrisSutkin (2008) describes them in terms of cognitive and non-cognitive dimensions (Fig. 6). Although skills and characteristics in the personality/non-cognitive dimension are difficult to teach, they need more emphasis, as they dominate the literature on good medical teaching.

FIG 6 Characteristics of good teachers in two dimensions (Reference Beishuizen, Hof and van PuttenBeishuizen 2001; Reference MarkertMarkert 2001; Reference Sutkin, Wagner and HarrisSutkin 2008).

MCQs

Select the single best option for each question stem

1. 1 The short-term effect of current undergraduate teaching programmes in psychiatry tends to be:

   1. a increased negative attitudes to psychiatry

   2. b enhanced neutral views to psychiatry

   3. c increased recruitment to psychiatry

   4. d significantly improved attitudes to psychiatry

   5. e not much change in attitudes to psychiatry.

2. 2 In undergraduates with neutral attitudes to psychiatry, a modifiable factor most likely to improve recruitment is:

   1. a the quality of teaching

   2. b the variety of the learning environment

   3. c exposure to psychiatric patients

   4. d multidisciplinary teaching rather than teaching by psychiatrists

   5. e being taught by junior doctors.

3. 3 The typical rate of decay of initial improvement in attitudes to psychiatry after an undergraduate teaching programme is reported to be:

   1. a a twofold reduction over 3 years

   2. b a threefold reduction over 1 year

   3. c a fivefold reduction over 5 years

   4. d very little decay over 3 months

   5. e negligible change in the first year.

4. 4 The phenomenon described by Kneale as creating a barrier against deeper learning and conveying messages beyond exams/assessment is:

   1. a experiential learning

   2. b the hierarchy of needs – e.g. self-actualisation

   3. c stigma against psychiatry

   4. d strategic learning

   5. e ‘bashing’ or belittling of psychiatry by other specialties.

5. 5 According to the educational literature, students’ intrinsic motivation to learn (i.e. achieve deeper learning) is most likely to be improved by their teachers’:

   1. a experience

   2. b humanistic/interpersonal skills

   3. c sound, subject-specific knowledge base

   4. d use of improvisation

   5. e structured approach to teaching.

MCQ answers

1

d

2

a

3

b

4

d

5

b