'Psychiatry is the most exciting and fun speciality of medicine'

June 5, 2009
by Greg Watson

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Psychiatry is the most exciting and fun speciality of medicine, the president of the Royal College of Psychiatrists (RCP) stated yesterday.

Professor Dinesh Bhugra was commenting on a "catastrophic" situation whereby only one in 10 newly-qualified psychiatrists are UK graduates.

Medical graduates who opt for psychiatry as their career must, during their six-year training, pass postgraduate RCP exams. This year, of the 519 candidates who sat the first postgraduate RCP exam sitting, only 64 (12 per cent) were UK graduates – a record low. The next sitting is in October.

Last year, incorporating both exam sittings, the totals were 230 UK graduates from 1,043 examinees; in 2007 it was 257 from 1,491, in 2006 it was 315 from 1,515; and in 2005 it was 388 from 1,372. The figures highlight the falling competition for psychiatry training places.

Around 400-500 psychiatry posts have to be filled in the NHS each year. Most psychiatrists employed from overseas come from India and West Africa.

The government points out that its investment in mental health has resulted in 64 per cent more consultant psychiatrists compared to 1997.

But in a bid to recruit more UK psychiatrists, Prof Dinesh Bhugra said: "The message to UK graduates is that this is most exciting and fun speciality in medicine.

"Where else would you use cinema, theatre, literature, neurosciences, psychology, sociology and anthropology to pull it all together? But a lot students and junior doctors are being put off for various reasons."

A Channel 4 report yesterday warned of a shortage of UK psychiatrists and a significant drop in the quality of trainee psychiatrists.

Prof Robert Howard, dean of the RCP, said: "Catastrophic is the word I would use for the shortage we are now facing. We have always struggled to recruit significant numbers but this year is particularly acute.

"It has got to the point where you can count the number of UK doctors coming into it in tens, when we have hundreds of training posts to fill.

"The doctors who are coming in from overseas to work in the UK: some are brilliant, and our president is a shining example. This is not being racist or unpleasant. But many of them [overseas doctors] have difficulties with communication and the nuances of the UK's culture. And if there is a speciality where it is essential to know the culture, it is psychiatry. There needs to be a balance.

"Overall, because of the lack of competition, we are giving jobs to some people who are 'appointable' but certainly not people who it fills our spirits to have given jobs to.

"The fact that we have to make a decision about the minimum standard cut-off point for potential 'appointability', and that we feel relieved when we find sufficient people who just scrape over this is damning enough."

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Endless risk assessments

From: Allan House, professor of liaison psychiatry, University of Leeds, England
Date: June 8, 2009

It's all right for Dinesh to say "Where else would you use cinema, theatre, literature, neurosciences, psychology, sociology and anthropology to pull it all together?" but the truth is that for many potential graduates the experience we show them is endless risk-assessments (courtesy of our mental health tsar), dirty dangerous wards (courtesy of our government) and the insulting banality of reducing all of human complexity to a diagnsis of "personality disorder" (courtesy of most of our profession and the RCP).

There's a monumental task to reverse this, and it won't be done by mixing arts with facile psychobabble. It needs "personal and national politics" in Dinesh's list.

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Too much neuroscience

From Louise Pembroke, mental health campaigner, London
Date: June 11, 2009

Well said Allan. It is hard to see how trainees/psychiatrists are allowed to use that wonderful list in practise with their current training.

Having looked at a MRCPsych exam - biology-biology-bit of psychology and more biology - it's little wonder psychiatrists are unable to converse about the content of people's experiences. [McCabe R, Priebe S, [2008] Communication and psychosis: it’s good to talk, but how? British Journal of Psychiatry 192, 404-405, doi; 10. 1192/bjp.bp.107.048678].

Medical students can tell some grim stories about teaching to undergraduates, such as being told to always suggest Olanzepine in practical vivas for anything diagnosed as psychosis from the actors. Through to consultants stating that “anyone who self harms has a borderline personality disorder, and is generally a horrible person with no hope”. Not much of the arts in there...although I would like to recommend all medical schools screen Terminator 2 and say, see - that's what happens when you don't believe your patients!

At Mind’s annual conference in 2007 there was a workshop looking at the topic of ‘Is the training of psychiatrists fit for purpose?’ There was broad agreement that current training of psychiatrists had too much emphasis on neuroscience with not enough attention paid to life experience and personal qualities. Cultivation of empathy, respect and humility is not always encouraged within general medicine. Workshop participants felt diagnosis and drugs were limited in their usefulness and that psychiatrists often didn’t engage with the context of people’s distress, nor appreciate social reality and difficulties as key factors in people’s distress.

There was agreement that psychiatrists spent too much time in hospital settings and needed to train and work more in the community, voluntary sector, and in user and advocacy projects. Also to be exposed to wider influences ie. faith traditions , shamanic and psychic studies, parapsychology, arts, philosophy.

I agree with Allan that what trainees actually get are endless scales, screens, inventories, risk assessments, risk crystal balls [ok I made that one up], facile proformas, and outcome measures. And of course Olanzepine and CBT and Olanzepine and CBT.

Oh the banality of 'personality disorder' - I couldn't agree more. Many nurses detest this diagnosis along with many service users. Even those of us who don't have the diagnosis detest it because we've witnessed how that diagnosis has decimated lives. Some nurses and service users want to set up an anti-PD diagnosis campaign, to get rid of the diagnosis from the DSM, in a similar vein to the CASL campaign for Schizophrenia.

I find it hard to see how psychiatry is fun or exciting to work in much of the time, I think it can be damaging to its workers. I'm amazed by those critical thinkers who manage to remain in a profession which is so risk aversive and evidence-based-obsessed. Backed up by bad politics and a mental health act which would have psychiatrists detain people just in case they commit an offence or default on medication. As a friend with drug induced tardive dystonia said to me: "Fun? depends which side of the hypodermic you're on".

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What alarming 'fun'

From: Phil Barker, honorary professor of medicine, nursing and dentistry, University of Dundee, Scotland
Date: June 11, 2009

Is it just me, or is there not something bizarre, stupid or offensive about claiming that "psychiatry is the most exciting and fun speciality of medicine". I suspect that many people who feel moved to consult a psychiatrist (or their families for that matter) will find the idea that any such a 'consulation' might be either 'exciting' or 'fun' for the doctor concerned, most alarming. Can't imagine paediatric oncologists (or any other medical speciality) framing itself as a 'fun' discipline.

Whatever psychiatry 'is', it seems clear it is not a medical speciality. There are indeed a lot of people who appear to need someone (or perhaps even lots of people) to help them deal with their various problems in living. Whether or not they need 'specialist doctors' is another question altogether.

Perhaps Professor Bhugra needs to 'go back to basics'. What 'exactly' does a medical speciality of psychiatry offer people, that they cannot find elsewhere? That seems far more realistic than trying to turn psychiatric medicine into something, which the mdia types would label 'sexy'!

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Clumsy and arrogant

From: Kim Sherrington, lead clinician/unit manager, day group therapy unit, Avon and Wiltshire Mental Health Partnership NHS Trust
Date: June 15, 2009

Such a clumsy statement may well be symptomatic of a branch of medicine that is still just as determined to call itself an exact science as it always has and therefore maintains the biological dominant discourse regardless.

The arrogance of our branch of medicine still bewilders and frustrates me after thirty years within said branch.

Despite the world populace view that it is life experience that causes mental health problems and that the debate as to what constitutes 'mind' or even if it exists continues, the medical profession, ably supported by Giant Pharma, continue the journey down the pathological road of 'explanation'. Hence the importance of choosing what one says and its effects carry little concern.

What will it take for the psychiatric medical establishment to let go of its modernist, 'expert' and arrogant stance and demonstrate some humility by acknowledging the truth about what it doesn't know?

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