Shrinking: The Recruitment Crisis in Psychiatry

Earlier this year I submitted this piece for the Morris Markowe prize, which the Royal College of Psychiatrists awards annually for the best short essay aimed at public education. Needless to say it didn’t win; the competition was fierce and the piece unremarkable. It tries to address some of the misconceptions around psychiatry, with the aim of getting more junior doctors to apply to specialise in it. I’m publishing it here so it finally sees the light of day and I’d really appreciate your thoughts.

Since I wrote the piece, the Royal College has announced that their recruitment drive is working: 95% of CT1 posts have been filled for the forthcoming year, a significant increase.

Shrinking: The Recruitment Crisis in Psychiatry

When a medical student finally emerges from their cocoon as a newly-qualified doctor, they spend the next two years rotating through a number of specialities. Getting a range of experience on the lowest rung of the ladder can be intense and unforgiving, but all doctors have been through it.

After those two years, there comes a choice: which single speciality would we like to train in further? This conundrum was presented to me last year. I could have worked in the relentless warzone of A+E, stitching up cuts and manipulating fractures. I could have become a surgeon; singular and intense. I could have chosen enduring relationships with patients and reasonable working hours by becoming a GP. I could even been a cerebral anaesthetist, complete with Zen-like calm.

But I didn’t choose any of those. I chose psychiatry.

The reaction was palpable. One of the few friends who could express their feelings about my decision beyond stunned disbelief and scornful profanity told me that it was “a total waste” of my modest medical promise.

My friends were not the only junior doctors to have considered a career in psychiatry to be an unattractive choice. The perennial “Cinderella speciality” is horribly understaffed nationwide, and the Royal College of Psychiatrists has rolled out a 5 year recruitment plan in a much needed effort to increase numbers of applicants and filled posts.

Down the psychiatric rabbit hole

But why is psychiatry so unpopular? There a few well-worn answers to this question. I think most of them are wildly unbased, and disproving them would do our recruitment, and image as a speciality, no harm.

One of the most common fears is of ceasing to be a “real doctor”. Prospective applicants dread the thought of being lost so far down the psychiatric rabbit hole, distant from the rest of medicine, that they’ll forget how many kidneys people have, or which end of a stethoscope goes in your ears. To a degree, this is understandable. Our breadth of knowledge does wane with time. But this is no different to any other speciality. I once knew a cardiologist who had to look up rheumatoid arthritis on Wikipedia. Orthopaedic surgeons are lambasted for not being able to read ECGs, and a gynaecologist wouldn’t have the foggiest idea what to do about your fungal nail infection.

In reality, modern psychiatry isn’t all that far removed from physical medicine. Plenty of the mental changes we see are caused by things like infections, drugs or thyroid problems, and we’re certainly no strangers to blood tests and head scans. Most psychiatric problems can be caused by neurological issues like strokes, dementia and epilepsy. Conversely, some psychiatric problems like anorexia can cause life threatening physical problems, so a thorough knowledge of the brain and body is essential. In addition, our patients are far more likely to suffer from obesity, diabetes and cardiovascular problems (and not just because of the drugs we give them!) so being competent at dealing with these issues is essential too.

The science of feeling

 Junior doctors also avoid psychiatry because they see it as unscientific. I agree that the sheer complexity of a person’s thoughts, emotions and interactions makes the scientific study of psychiatric illness much tougher than studying something discrete like a heart attack. But study it scientifically we do; and to great extent. As well as endless clinical trials of medication, you can’t throw a brick these days without hitting some state-of-the-art research on the genetics or neurobiology of illnesses like schizophrenia. We’re ever closer to understanding the causes of problems like autism, and we also successfully apply scientific methods to the study of things that aren’t inherently medical, like types of talking therapy. Moreover, we get to do lots of “touchy-feely” research on how people feel, which is vitally important and fascinating. No doctor could fail to find something that grabs their professional attention, and there are a lot of opportunities to get involved. In other specialities you’d have to sell your first born child to help with research, but in psychiatry, we seem to get offers every week.

The incurables

I’m often told by other doctors that they could never be psychiatrists because our patients never get better. I just don’t recognise that pessimism when I go to work. The majority of our patients recover completely and move forward with their lives, and the patients that aren’t able to improve fully are frequently helped substantially. Small steps, like relieving plaguing paranoia, easing low mood or anxiety, or helping patients build better relationships with their families are great goals in themselves.  For perspective, endocrinologists can’t cure Type 1 diabetes, respiratory physicians can’t cure emphysema and infectious disease specialists can’t cure HIV. In fact, palliative care doctors, who rightly hold an indispensible place in medicine, rarely cure anything. A large part of any doctor’s work is limiting the pain and suffering incurred by incurable problems. But only psychiatrists get stick for not doing enough curing.

The positives

As well as dispelling mythical criticisms, psychiatry can boast unique positives. The diversity of psychiatric sub-specialities is refreshing and challenging. They stretch from child services, through adult and forensic services, psychotherapy and addictions, all the way to old age psychiatry. Also diverse are the ways we help people: long gone is the cinematic caricature of the drugged-up, forgotten mental patient. The modern manner of care is to mix social and psychological support with a hopefully minimal amount of medication, and contrary to common assumption we learn as much about therapy as we do about tablets. I work with all manner of other professionals, like psychologists, social workers, and specialist nurses. Their vivid opinions, both on what is best for a particular patient, and on psychiatry as a whole, help to broaden my horizons and keep me thinking.

The greater amount of time I have with my patients means that I can get to know them as people instead of as “the gall bladder in bed 6”, like I had to as a medical doctor.  Being entrusted with the information they give me about their astonishing and colourful lives is a tremendous privilege. I’ve met concentration camp survivors, refugees, authors, actors and activists. I have grown. The conversations I have are so much more engaging now too; asking about a chest infections gets tiresome by the 100th time you’ve done it, but talking to someone about the voices they hear and the reasons why they think people want to kill them never gets boring. Bodies are all similar, but minds are beautifully unique.

I’m not totally delusional. I don’t think every junior doctor is a psychiatry convert waiting to happen. But I think psychiatry would have a lot more applicants and a far better reputation if people saw our true face. We are modern, caring, intelligent, energetic and various. But we’re also really short staffed. Come help us out.

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