Career: Not a couch in sight

IN JUNE of last year Channel 4 News aired a story highlighting a "catastrophic" shortage of psychiatrists in the NHS as fewer and fewer UK-trained medics apply for posts. This has led to an over-reliance on overseas doctors to fill training posts. Just one in eight doctors sitting professional psychiatric exams in 2009 were UK graduates.

It’s difficult to understand why psychiatry is facing a recruitment crisis in the UK as it is one of the most interesting and eclectic of all medical specialties.

“The combination of different scientific disciplines covering areas as diverse as neuroscience, psychology, and social science, all brought together within a person-centred approach, is hard to beat within medicine,” writes consultant psychiatrist, Dr Alan Lee.

“I have never once regretted my decision to train as a psychiatrist.”

Psychiatry involves the diagnosis and treatment of patients with mental health problems such as depression, anxiety, personality disorders, learning disabilities and schizophrenia. Management involves a combination of measures including drugs, psychological treatments, working to improve home environments and social networks, and – very occasionally – use of physical treatments such as electroconvulsive therapy (ECT). Psychiatrists work with a range of other professionals, including clinical psychologists, social workers, psychiatric nurses and occupational therapists. Teamwork is essential and the apparent non-hierarchical nature of psychiatric MDTs can seem unusual to new trainees.

Mental health disorders are not diagnosed with a laboratory test. Great communication skills are the most important asset for a psychiatrist. As an added challenge, some of the most seriously ill patients have no insight into their own illness and may need to be treated without their consent under the provisions of the Mental Health Act. A good psychiatrist uses his or her communication and persuasion skills, as well as legal powers, to convince patients that they should cooperate with treatment plans. Most importantly, psychiatric patients get better with treatment. Many patients with psychosis or severe mood disorders will recover, return to work and can rebuild their relationships and lives with psychiatric support.

Entry to the profession

First exposure to the practice of psychiatry for most doctors is during foundation training rotas. Most trusts and deaneries have created foundation posts in psychiatry but numbers around the country vary. On completion of FY2, trainees interested in pursuing psychiatry as a career must apply for specialty training. Entry criteria are based on the key competencies of a good psychiatrist: medical expert, communicator, collaborator, manager, health advocate, scholar and professional. Professor Rob Howard, Dean of the Royal College of Psychiatrists, advises: “If you are interested in people and want to be engaged and involved in the lives of your patients and make a difference to them and their families – then wewant you in psychiatry”.

Many of the qualities of a good psychiatrist can be developed with training but an ability to communicate with patients and their carers and liaise with other professionals are important starting points. This is assessed via a combination of the FY2 portfolio, CV-based questions, a structured interview and assessment of teamwork and empathy potential. There are other ways to demonstrate your commitment to the specialty such as working with voluntary organisations like the Samaritans and Sane Line, or arranging to shadow a local consultant psychiatrist to gain first-hand knowledge of the work.

Training and practice

Specialist training in psychiatry takes 6 years and is divided into 3 years of core training (CT1–3) and 3 years of specialty training (ST4–6). Core training is spent in a wide variety of posts lasting four to six months. To move on to specialty training, STs must pass three written exams and one clinical exam in order to obtain Membership of the Royal College of Psychiatrists.

ST4-6 training is spent in one of the six different psychiatry specialties: general adult, old age, child and adolescent, learning disability, psychotherapy and forensic.

Workload and duties for psychiatry trainees vary widely between jobs. STs are usually responsible for the day-to-day management of in-patients and community patients and review them regularly, presenting updates at ward or community rounds. They also see both new and follow-up patients in out-patient clinics. STs can be involved in administering ECT and assessing patients presenting to accident and emergency. On-call duties are usually less hectic than in the acute specialties and many rotas allow you to be on call from home.

The future

Considering the current challenges it’s likely that the NHS will put more resources into the recruitment of psychiatry trainees. Increased investment has already meant that there are 64 per cent more consultant psychiatrists than there were in 1997. The College is also rethinking how the specialty is perceived among medical graduates and is very keen to show trainees just how much enjoyment and satisfaction a career in psychiatry can deliver.

"I think psychiatry has struggled to attract UK graduates in the past because it has an image of otherness and weirdness; and a misconception that we don't ever cure people,” says Professor Howard.

"The fact is that psychiatrists play a vital role in getting people back to work, keeping them out of the justice system, and assessing who is at risk."

Or as Dr Alan Lee puts it: “In psychiatry you can really make a difference to people struggling with the most devastating illnesses and can help them to return to satisfying and fulfilling lives.”

For more information go to www.rcpsych.ac.uk

Jim Killgore is editor of MDDUS Summons

Q&A Dr Jon van Niekerk, ST6 in psychiatry

• What attracted you to psychiatry? My medical student placement in psychiatry was incredibly interesting and varied but too short to do the specialty justice. I decided to do my elective at a big mental health hospital in South Africa and it was here that I became fascinated with the diversity and richness of the specialty. During my specialty training I have had many opportunities to further my understanding of psychology, psychotherapy, philosophy, law and neurology – all subjects that make the specialty even more interesting. I became increasingly curious about what made us behave, think and feel the way we do. It is a privilege to continue to have the opportunity to ask these important questions in life over the span of a career.

• What do you enjoy most about the job? In psychiatry the doctor is the drug most prescribed. The doctor-patient relationship is crucial and communication skills are more important than ordering investigations or following a set algorithm. As a psychiatrist you have the time to really get to knowyour patients well. It can be incredibly rewarding to be able to make a real difference to patients when they are at their most vulnerable. It could be argued that we are the only medical profession that can claim to be truly holistic.

• Are there any downsides? Psychiatry continues to suffer from stigma in the wider society, but also within the medical profession itself. The challenge is for us to advocate for our patients and for our specialty. Psychiatry has some of the most effective therapeutic interventions that medicine has at its disposal, but this is unknown to the wider general public.

• What do you find most challenging? I find it frustrating when I see mental health patients receive poor physical healthcare. There remains an unfair difference between the physical healthcare that patients with a psychiatric diagnosis receive and the rest of the population. This is a challenge for both psychiatry and primary care and I would like to see much closer collaboration in the future. The mortality figures for those with severe and enduring mental health problems are unacceptable.

• What about the role has most surprised you? I have been surprised by the compassion and kindness of carers. I continue to be amazed how these individuals are willing to put their own needs aside and take up these challenging roles for sometimes decades. A lot of our patients need the stability and continuity that carers provide to be able to function in a community setting. We would not be able to deliver care to a lot of patients without these individuals. In fact the whole of the NHS would probably collapse without carers.

• What is your most memorable experience so far? I remember administering electroconvulsive therapy (ECT) to a patient that had a severe depressive episode. She was mute and had stopped eating and drinking and there were serious concerns that she might die. A few minutes after finishing the ECT clinic I was in the nursing station, when someone knocked at the door. A patient started asking me in a very assertive way, why the NHS complained about lack of money when they left windows open and the heating on. Much to my surprise I realised that this was the lady that was in a catatonic depressive state only minutes ago!

• What advice would you give to an FY considering psychiatry? Despite psychiatry being the third biggest hospital specialty, we only have about 5% of Foundation posts. Therefore most of you will have to evidence your interest in the specialty in other ways. I would encourage those interested to join the free associateship that has been set up by the Royal College of Psychiatrists. There are several benefits, including free annual conferences, summer schools, an e-newsletter full of advice and free subscription to the College’s journals. A taster session with a psychiatrist can also be invaluable and GP placements are also good to witness primary care psychiatric presentations. Audits are an easy way of showing interest as well. Psychiatrists are usually very approachable and willing to help.