WPA Position Statement on Recruitment in Psychiatry

The problem of recruitment in psychiatry is universal. There are very few countries where this problem does not exist. Variations have to be seen in the context of health care systems, training options and educational systems.

The World Health Organization has set a target of one psychiatrist per 10,000 population globally. While this target is met in most European countries, North America and Japan, just under half of the world population live in countries with less than one psychiatrist/100,000 population. The rates are extremely low throughout Africa, and low in South America, Southeast Asia and Subcontinental Asia, with high urban‐rural disparity.

Despite the relatively high numbers of psychiatrists, many high‐income countries are suffering from a perceived “recruitment crisis”. In many countries vacancy rates in training posts remain over 10%. To complicate matters further, often international medical graduates who may see psychiatry as popular take up much of the slack, contributing to “brain drain” from their countries of origin.

Who chooses psychiatry, and what influences their choice? Many students choose medicine for the specific purpose of doing psychiatry, but some change their mind during their training. Others see the process through. Some students fall into psychiatry either passively or choose it actively. The reasons are often complex1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11.

Most of the studies have focused on understanding issues in Europe and the US. As duration of undergraduate training in psychiatry varies from 2 to 8 weeks, it is important to explore and understand these variations. WPA studies have shown that female doctors are slightly more likely to choose psychiatry. A personal or family history of mental illness increases the likelihood of choosing psychiatry.

Medical students with undergraduate exposure to psychology or social sciences are more likely to choose psychiatry. Having a positive experience of psychiatry teaching and placement with clinical activities and exposure to psychotherapy during medical school, and/or additional exposure through clinical electives, also influence the choice of psychiatry.

What factors negatively influence recruitment? A fall in levels of interest in psychiatry during undergraduate training can be attributed to poor exposure to teaching, a lack of psychiatric facilities and limited clinical exposure.

Furthermore, the quality of mental healthcare in many parts of the world is extremely poor, and largely inpatient, with little opportunity for exposure to community‐based psychiatry or other specialities. As such, students may be turned off psychiatry by what they witness during placements.

The relative lack of financial reward can also affect career choice. Other factors are stigma against the psychiatric profession and against mental illness in general, resulting in perception of psychiatry as unscientific, ineffective, or apart from mainstream medicine. There is a perceived lack of respect from colleagues in other specialities and a poor public image.

Furthermore, misconceptions and prejudices against the mentally ill themselves may make psychiatry an undesirable proposition. The stereotypes of psychiatric patients being dangerous or unpredictable and chronicity of psychiatric disorders can also put medical students off psychiatry.

How can recruitment be improved?

• By increasing the availability and quality of psychiatric care, especially in low‐ and middle‐income countries (LMICs), with a focus on training in community‐based structures.

• By increasing the quantity and quality of psychiatric teaching and clinical attachments within medical schools, especially in LMICs, and making psychiatry an examinable part of the curriculum at par with other specialities. Psychiatry should be an inherent part of medical school curriculum from day one. Integrating physical and mental health teaching with better focus on public mental health is important.

• By reducing stigma against mental illness through public education campaigns and educational projects aimed at school‐age students, and by challenging media representation of mental illness and focusing on eliminating discrimination against individuals with mental illness.

• By increasing representation of mental health professionals on medical school interview panels where possible and selecting candidates with attributes likely to guide them towards psychiatry.

• By an increased and better involvement of psychiatrists in medical school curriculum development, healthcare policy development, healthcare lobby groups, and medical accreditation bodies.

• By encouraging and supporting the development of extra‐curricular “enrichment” opportunities that give medical students additional teaching and clinical exposure during their training. These may include a psychiatry society or special interest group, elective and residency programmes, early experience programmes, special study modules, using medical humanities in the curriculum and developing local solutions.

Greg Shields1, Roger Ng2, Antonio Ventriglio3, Joao Castaldelli‐Maia4, Julio Torales5, Dinesh Bhugra6
1South London and Maudsley Trust, London, UK; 2Department of Psychiatry, Kowloon Hospital, Kowloon, Hong Kong; 3Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; 4Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil; 5Neuroscience Department, National University of Asuncion, San Lorenzo, Paraguay; 6Institute of Psychiatry, King's College London, London, UK