Recruitment problems in psychiatry: just a matter of more exposition?

In this issue of Acta Psychiatrica Scandinavica, Holm-Petersen et al. (1) emphasize that, due to severe image problems, psychiatry is a less attractive option compared with other medical specialties. This is in agreement with others (2, 3) although not found in all cultures (4, 5). The authors (1) suggest that the problem is found in early student life and the cure is to have more exposure to psychiatry to improve their knowledge about the work of psychiatrists. The good news is that, contrary to its reputation, psychiatry is highly regarded among medical students. More exposure to psychiatry, therefore, is very important to promote a more positive image of the specialty. The study outcome on medical students’ attitudes towards psychiatry was found to be quite good, after a 4-week mandatory psychiatric affiliation; the proportion of medical students that considered psychiatry as a possible career option doubled (from 12.7% to 25.0%). In the article by Holm-Petersen et al. (1), at first glance, it seems that psychiatry is considered to be a low prestige specialty, as psychiatry obtained the lowest score for all questions, with the exception of the attractiveness of working hours and the psychological working environment, in a questionnaire about the attractiveness of different medical specialties. In a different study (3), psychiatry was also positively rated by medical students to be intellectually stimulating and interesting. However, although statistically significant differences may be obtained in such studies, when quantitative questionnaires are applied on qualitative questions, such studies inherently suffer from a tremendous lack of information. Consequently, small differences on a quantitative scale, e.g. when rating psychiatry somewhat lower than other medical specialties, they are very difficult to interpret meaningfully. From such quantitative studies, it may be premature to conclude from these results that there is a crisis in psychiatry. However, plausible, future research documenting the actual impact of such a low rating among medical students on the recruitment of psychiatry students is needed. Also, there is an obvious need for qualitative as well as quantitative research documenting different steps on the pathway to a medically specialized career (6). Although more psychiatrists are needed, only approximately 1 in 20 students would be required to choose psychiatry as their specialty. Early head-hunting for the most talented students seems to be a better option than waiting for doctors to desert their posts in other specialties. The latter option also gives rise to the undesirable misunderstanding that if all else fails one can always become a psychiatrist. However, this saying is partly true, as psychiatry, e.g. in Denmark, demands the lowest scientific knowledge for admission (7). This fact about ‘easy’ admission probably underlines the critical need to evaluate those entering specializing for psychiatry. It is too simplistic to say that one makes a single choice to embark on a medical career; choosing a specialty is a process of socialization and development, i.e. several elements interact over the years. First, socialization may be facilitated if psychiatrists give the education of students the highest priority (8–10). Second, involving medical students and young doctors in psychiatric research projects (6, 11). Surprisingly, one study pragmatically suggests that there may be more scope for improving recruitment by influencing the general intake of medical students rather than focusing on undergraduate teaching (6). The study by Holm-Petersen et al. (1) touches on the fact that 20% of psychiatric positions are vacant in many western countries; however, this study only mentions two types of psychiatric affiliation. It is time to consider vacancies that should be filled with medical students rather than by doctors deserting other specialties, as medical students inherently possesses better recruitment potential than doctors who end up in psychiatry as a last resort. Future studies to investigate the effect of such deputyship by medial students and the effect of their involvement in research projects on recruitment to psychiatry are strongly encouraged. According to the specific organization, and even according to geography, psychiatry has, in some countries, been separated from other neuroscientific disciplines. In, for example, the Metropolitan Region of Denmark, psychiatry has been secluded from the hospital system due to the impact of political decision makers. Such decisions give rise to the misunderstanding that psychiatric disorders are socially, rather than medically, defined and objectively detectable disorders. It is of concern that incorrect categorization of psychiatry may not only give rise to the stigmatization of psychiatric patients, but also seriously undermine the reputation of psychiatry as a medical discipline (12). All psychiatrists have encountered even highly educated people who are not aware of the difference between psychiatry and psychology. The medical profile of psychiatrists can vary widely and students may consider the psychiatrist to be a dubious role model. For decades, many psychiatrists have been involved in rapidly changing psychotherapeutic approaches. Such psychotherapeutic approaches have been based, more or less, on research. This is not discussed here, but it often seems unintelligible why such treatment has been widely allowed to invade the education of psychiatrists. As an example, it can be mentioned that in Denmark, several hours of systematic supervision in psychotherapy is required in psychiatric education, but no systematic knowledge of psychopharmacology or psychopathology is documented to be mandatory in the same way. Despite such inconsistencies, psychiatry is facing a major medical breakthrough, and the neurobiological, epidemiological and genetic understanding of psychiatric disorders is rapidly growing. The availability and use of psychotropic drugs are also increasing rapidly. These scientific developments aggravate the need for a solid medical foundation in psychiatry. It is obvious that when students commence a medical education, they expect to work as medical doctors when they graduate. It also seems obvious that such students, after several years of learning anatomy, surgery, biochemistry, pathology, and pharmacology, etc. do not have the ambition of using e.g. group therapy as their first priority. These considerations are not meant to devaluate such therapies, only to raise the question about balancing. This point of view is analogous to, e.g. orthopedic surgery where the surgeon knows when to initiate physical rehabilitation; however, he would never train the patient himself. No-one would ever question the statement that an occupational therapist possesses the best qualifications for such rehabilitation. However, in psychiatry, medical doctors are met with demands of a non-medical nature although such demands could be better dealt with by others, e.g. psychologists, social care workers, nurses, etc. (13). As long as psychiatry is regarded only as a quasi-medical specialty, medial doctors will be reluctant to choose (or migrate into) psychiatry. This may result in pressure on demand in two ways: recruitment problems and a work overload on existing psychiatrists. Further, psychiatry will be the option for those found to be inappropriate in first-rated specialties and a malignant spiral, worsening the image of psychiatry would begin. The present study by Holm-Petersen et al. (1), in agreement with others, underlines the need to reframe psychiatry into a transparent medical discipline among other neuroscientific medical disciplines. This is obviously in the interest of patients, too. Let the baker make the bread and let the doctor do psychiatry.