Psychiatric recruitment is facing a crisis. Changes to immigration rules have exposed the UK's dependence on international medical graduates to fill psychiatric training posts. In 2011, only 78% of the 478 core trainee year 1 (CT1) vacancies were filled in England and Wales. This is not a new problem, with reports on recruitment problems dating back to the 1970s. Reference Scott1-Reference Sierles, Yager and Weissman3 Urgent action is needed across the entire continuum of medical training to make a career in psychiatry more attractive.
In the UK, all newly qualified doctors must complete the 2-year generic Foundation Programme before embarking on specialty training. This transitional phase is important in informing career decisions. Shah et al Reference Shah, Brown, Eagles, Brown and Eagles4 reviewed experience in Scotland and found that by doing a psychiatry placement, foundation doctors become much keener to pursue psychiatry as a career, with 16% of foundation year 2 (FY2) doctors placing it as their first choice, compared with 6.8% of foundation year 1 (FY1) doctors who were yet to undertake their psychiatry placement. They found that foundation doctors’ concerns about psychiatry included the perceived poor prognosis of patients, the lack of scientific basis and the standing of psychiatry among doctors and the public. Doctors in foundation year 2 who had experienced psychiatry were more positive about patients’ prognosis than those in year 1 who had had no exposure to psychiatry. Reference Shah, Brown, Eagles, Brown and Eagles4 However, it is important that foundation psychiatry placements are well structured and supervised. Reference Welch, Bridge, Firth and Forrest5
Goldacre et al Reference Goldacre, Turner, Fazel and Lambert6 report that experience gained through the completion of postgraduate jobs was more important for influencing career choice in other specialties than psychiatry at the end of the first postgraduate year but was of equal importance at the end of the third year. They suggest that this difference is likely caused by the lack of early years’ psychiatry experience. Lowe & Rands Reference Lowe and Rands7 also conclude that the provision of programmed postgraduate training in psychiatry in UK foundation schools is inadequate, suggesting that there are far too few foundation posts in psychiatry.
This retrospective cohort study investigates whether there is a relationship between a psychiatry placement in the Foundation Programme and appointment to core psychiatric training.
Method
The UK Foundation Programme Office (UKFPO), which is the national coordinating body for this stage of training, undertook a survey of FY2 doctors’ career destinations when they completed the Foundation Programme in August 2011. Data were gathered between March and September 2011 in partnership with Postgraduate Deaneries and their foundation schools. The schools used a variety of methods to gather the data, for instance embedding the nationally agreed career destination questions in their existing surveys, or using the UKFPO online survey or the UKFPO paper-based questionnaire.
Box 1 Questionnaire questions and possible answers
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1 Did you experience psychiatry during your foundation training?
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a No experience during the Foundation Programme.
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b Part of rotation before applying to specialty training.
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c Part of rotation after applying to specialty training.
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d Undertook taster before applying to specialty training.
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e Undertook taster after applying to specialty training.
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2 If appointed in the UK, which clinical training programme have you been appointed for?
Foundation doctors were asked whether they experienced psychiatry during their foundation training and to which clinical training programme they have been appointed (Box 1). Core psychiatry training was one of the options.
A psychiatry placement was defined as an approved Foundation Programme placement lasting 3, 4 or 6 months. A taster was defined as exposure to the specialty, in addition to the structured Foundation Programme placement.
Results
All 25 foundation schools participated in the survey. There were a total of 7301 FY2 doctors in these schools who successfully completed the Foundation Programme; 6913 (95%) responded to the questionnaire.
It emerged that 937 doctors (13.6%) had a psychiatry placement and an additional 70 (1.0%) had a psychiatry taster prior to the specialty application period. Thus, overall 1007 (14.6%) foundation doctors had psychiatry exposure before applying for specialty positions. Further, 241 (3.5%) reported that they rotated through a psychiatry placement and 7 (0.1%) undertook a psychiatry taster after the specialty application period opened, suggesting that some trainees considered applying in later rounds. However, for the purpose of this study the cohorts are defined by experience before the opening of specialty recruitment.
Out of the 937 foundation doctors who had a psychiatry placement before applying for specialist positions, 140 (14.9%) subsequently entered core psychiatry training. In contrast, out of the 5976 foundation doctors who did not have a psychiatry placement, just 109 (1.8%) chose core psychiatry training (χ2 P = 0.0008; risk ratio 8.19). Further analysis revealed that of the 109 foundation doctors who had not undertaken a psychiatry placement before applying for specialty training, 30 (27.5%) had undertaken a psychiatry taster. Therefore, only 79 (1.1%) foundation doctors chose core psychiatry training without any prior foundation psychiatry exposure (Table 1).
Table 1 Foundation doctors with psychiatry exposure and their subsequent career choice
| Number of foundation doctors |
Doctors entering core psychiatry training n (%) |
Doctors entering other posts n (%) |
|
|---|---|---|---|
| Psychiatry placementFootnote a | 937 | 140 (14.9) | 797 (85.1) |
| Psychiatry tasterFootnote b | 70 | 30 (42.9) | 40 (57.1) |
| No psychiatry placement | 5976 | 109 (1.82) | 5867 (98.2) |
a. Approved Foundation Programme placement of 3, 4 or 6 months.
b. Exposure to the specialty in addition to the structured Foundation Programme placement.
Discussion
This study found a significant association between a foundation psychiatry placement and appointment to core psychiatric training. It demonstrates that, proportionally, significantly more doctors with a Foundation Programme placement in psychiatry go into psychiatry training compared with foundation doctors with no psychiatry placement.
The study also highlights the potential value of tasters. Nearly a third of those who did not have a psychiatry placement during their foundation training but chose core psychiatry training as their next career destination had undertaken a taster in psychiatry. The Royal College of Psychiatrists is actively encouraging structured taster weeks for foundation doctors, having recently produced taster templates. 8
Currently, less than 20% of foundation doctors have a Foundation Programme placement in psychiatry. 9 It is possible that many of the foundation doctors in our study were already considering psychiatry as a career choice before their Foundation Programme placement; the study did not ask about prior career aspirations. It is probable that those interested in pursuing a career in psychiatry were more likely to express a preference for and to be allocated to a rotation with psychiatry. However, as noted earlier, experience in Scotland suggests only 6.8% of those allocated to a psychiatry placement ranked psychiatry as their preferred career at the beginning of their foundation training compared with 16% at the end. Reference Shah, Brown, Eagles, Brown and Eagles4 The data gathered in Scotland coupled with the results of this study suggest that placements and tasters in psychiatry can have a positive impact on a choice to pursue psychiatry as a career. This question, however, is only likely to be fully addressed by a prospective cohort study looking at career intentions related to clinical experience.
The value of a psychiatry placement is not confined to influencing career choice. Psychiatry placements enable foundation doctors to acquire, consolidate and demonstrate their abilities to care for patients with mental health problems; a vital skill set for all specialties. It is for this reason that we see psychiatry as a core specialty that must have a greater presence in the Foundation Programme.
This study provides further evidence to support calls to expand the number of psychiatry placements during the Foundation Programme. In addition to increasing the opportunities to more fully meet the outcomes set out in the Foundation Programme curriculum, this should increase the pool of doctors considering psychiatry. The Department of Health, following the advice of the Medical Programme Board and the Psychiatry Taskforce, has written to strategic health authorities in England asking them to increase the proportion of FY1 posts in psychiatry to 7.5% by 2013 and FY2 posts to 7.5% by 2014. This increase in FY1 posts will have to be funded by decommissioning posts in overrepresented specialties and transferring the resources to psychiatry. Expanding the number of FY2 posts will be even more challenging and will typically depend on conversion of core training posts, service posts or transferring resources from other parts of the medical training budget. It is essential that foundation placements are of high quality, structured and well supervised. Foundation doctors must also experience appropriate, balanced, psychiatry placements to avoid decision-making based on inaccurate perceptions.
Funding
This work was funded by the four UK health departments as part of the UKFPO's work plan for 2011/2012.
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