Discussion

This first national survey of UK undergraduate psychiatry placements in over a decade reveals that there have been few significant changes, especially in placement structures and content. Crucially, very little has changed in terms of the length of psychiatry placements or the variability of placement opportunities across the nation. A few uniformities have persisted across medical schools, including core curriculum content, methods of assessment and the continued use of psychiatry in-patient wards as a core placement for medical students.

The total duration of the main psychiatry placement across the undergraduate curriculum varied significantly across the medical schools, from 4 to 12 weeks. This is similar to the 4 to 11 weeks of psychiatry placement reported in a national survey of UK medical schools in 2009.^{Reference Karim, Edwards, Dogra, Anderson, Davies and Lindsay7} Placements should be of sufficient duration for undergraduates to observe changes in patient presentation and improvement in mental state over time, which can positively influence their views of psychiatry.^{Reference Appleton, Singh, Eady and Buszewicz16} Longer placements may help undergraduates to feel better embedded into clinical teams.^{Reference Appleton, Singh, Eady and Buszewicz16} An international survey of over 2000 medical undergraduates in 2010–2011 found no statistically significant association between the duration of psychiatry teaching and likelihood of choosing a career in the specialty; but greater exposure to psychiatry teaching correlated with improved attitudes towards psychiatry, as measured by the 18-item Attitude to Psychiatry Scale (ATP-18).^{Reference Farooq, Lydall, Malik, Ndetei and Bhugra17}

Broad variation was demonstrated in the availability of optional psychiatry modules and enrichment activities across medical schools. Involvement in enrichment activities is positively associated with choosing a career in psychiatry,^{Reference Farooq, Lydall, Malik, Ndetei and Bhugra17} but such findings are prone to self-selection bias. In a 2018 survey by the RCPsych, 26% of medical undergraduates reported undertaking a special study module or elective in psychiatry, 77% of whom felt that it increased their interest in psychiatry.⁸ Involving undergraduates in extra-curricular psychiatry opportunities near the start of their degree programme can dispel any negative preconceptions they may have about the specialty. For example, extra-curricular shadowing of core trainees in psychiatry has been found to promote and sustain positive attitudes towards psychiatry among first-year medical undergraduates.^{Reference Holt, Mirvis, Bao, Cross, Hussain and Hutchings15}

The integration of psychiatry teaching with other specialties in the undergraduate curriculum was common across the 27 medical schools and has seemingly become more common since the last national survey of psychiatry curricula in 2009.^{Reference Karim, Edwards, Dogra, Anderson, Davies and Lindsay7} In the current study, 79% of the medical schools reported integrating child and adolescent psychiatry teaching into paediatric placements, compared with 19.2% in the previous national survey.^{Reference Karim, Edwards, Dogra, Anderson, Davies and Lindsay7} These integrated teaching methods may help undergraduates to better understand multi-morbidity and the interface between physical and mental health, enhancing their abilities to provide holistic care. They may also reinforce the need to recognise and manage acute mental health issues in all healthcare settings, as expected by the GMC.¹⁸ A cross-sectional survey of two medical undergraduate cohorts at one UK medical school found that undergraduates who experienced more integrated teaching of psychiatry with other specialties held improved attitudes towards psychiatry, psychiatric patients and careers in the specialty.^{Reference de Cates, de Cates, Singh and Marwaha19}

Exposure to different psychiatric subspecialties can enhance undergraduate knowledge of psychiatry, positively influence undergraduates’ views of the specialty and demonstrate the range of opportunities afforded by a psychiatric career.⁸ There were large discrepancies in the coverage of psychiatric subspecialties across and within the different medical schools in our survey. Some respondents suggested that this was due to students undertaking placements in different hospitals, which offered different clinical services; however, online teaching and extracurricular events could be utilised to make specific experiences accessible to larger audiences. This variation of exposure was similarly reported in the earlier national survey of UK medical schools in 2009 and is consistent with qualitative reports of variable undergraduate experiences of psychiatry among psychiatry trainees.^{Reference Karim, Edwards, Dogra, Anderson, Davies and Lindsay7,Reference Appleton, Singh, Eady and Buszewicz16} Other studies have reported similar differences in exposure to eating disorder and perinatal psychiatry teaching across UK medical schools.^{Reference Ayton and Ibrahim20,Reference King, Crowley, El-Maraghy, Davis, Jauhari and Wilson-Jones21} Quality assurance systems are vital to ensure that high standards of psychiatry teaching, support and learning opportunities are offered across different placement sites.^{Reference de Cates, de Cates, Singh and Marwaha19} UK medical schools should explore opportunities for undergraduates to spend time at alternative locations if specific subspecialty experiences are not available at their individual placement site.

Clinical academics and National Health Service (NHS) psychiatrists remain the most frequently involved professionals in delivering undergraduate psychiatry teaching in the UK, but there are growing opportunities for teaching to be delivered by lived experience educators (patients and/or carers) and non-medical members of the multidisciplinary team, such as pharmacists and psychologists. Involvement of lived experience educators in psychiatric education can lead to reduced stigma, greater empathy and improved understanding of holistic care among medical undergraduates.^{Reference Player, Gure-Klinke, North, Hanson, Lane and Culyer22–Reference Dijk, Duijzer and Wienold24}

The reported significant shift to online modalities to deliver teaching during the COVID-19 pandemic similarly occurred in other medical specialties and has been reported previously.^{Reference Steohr, Müller, Brady, Trilla, Mähringer-Kunz and Hahn25} Key benefits of online teaching include improved flexibility and convenience of accessing learning, opportunities to involve speakers from diverse locations and the promotion of digital literacy.^{Reference Steohr, Müller, Brady, Trilla, Mähringer-Kunz and Hahn25,Reference Hewson, Mahalingappa, Dave, Huline-Dickens and Casey26} On the other hand, potential disadvantages of virtual learning include reduced socialisation among faculty and undergraduates; challenges teaching non-verbal communication; reduced opportunities to see acutely unwell patients and observe the functioning of multidisciplinary teams; and technological problems impeding learning.^{Reference Steohr, Müller, Brady, Trilla, Mähringer-Kunz and Hahn25,Reference Hewson, Mahalingappa, Dave, Huline-Dickens and Casey26} Some of the medical schools in our survey described shortening their psychiatry placements during the pandemic, but the majority did not. Similarly, a recent study reported that two-thirds of medical schools made no alterations to the duration of psychiatry modules during COVID-19, while 12.5% increased and 20.8% reduced them.^{Reference Leung, Ajaz, Bruce and Korszun27} Some of our surveyed medical schools expressed plans to implement blended teaching models, combining face-to-face and virtual learning post-pandemic. This is echoed in other research, where 87.5% of medical schools reported long-term changes to psychiatry teaching persisting beyond the pandemic.^{Reference Leung, Ajaz, Bruce and Korszun27} Online psychiatry teaching and virtual placement activities, given their scalability, may support the planned expansion of medical undergraduate numbers in the UK by increasing teaching capacity.²⁸

The MLA should standardise undergraduate medical curricula since UK medical schools will be required to ‘map’ their curriculum to this examination. This could reduce variation in undergraduate experiences of psychiatry across UK medical schools. No medical schools in our survey reported removing from their curriculum psychiatry content that falls outside the scope of the MLA; however, concerns exist that learning and teaching of such topics could become de-prioritised.^{Reference McKechnie, Parmar, Armstrong, Pratt, Pope and Alberti29} Collaboration and sharing of ‘best practice’ between institutions could standardise and improve undergraduate experiences of psychiatry, alongside following the RCPsych guidance for medical schools. Improving the quality of undergraduate psychiatry education is imperative in order to build a skilled workforce and positively influence patient outcomes.