Psychiatric secrets of success: who wants to be a specialist registrar?

Abstract

This paper aims to help trainees successfully negotiate the important ‘step up’ from senior house officer or equivalent grade to specialist registrar. It outlines the current structure of higher specialist training programmes in psychiatry, stresses the importance of early planning during basic specialist training and provides a guide to success in the shortlisting and interview stages.

Completion of basic specialist training, with the award of the MRCPsych, is an important milestone for psychiatric trainees. By this stage, most trainees will know which branch of psychiatry they wish to pursue at specialist registrar level. Since 1997, completion of the Calman reforms to higher specialist training has required specialist registrars to be recruited to training programmes rather than to individual posts (Department of Health, 1998). These reforms aligned the UK system of specialist training with the European Union directives on medical training (Catto, 2000). The subsequent restriction of national training numbers available for each psychiatric training scheme has placed an important hurdle in the path of prospective higher trainees – the specialist registrar interview.

Higher specialist training programmes

There are currently six higher specialist training schemes in psychiatry, covering general adult, old age and forensic psychiatry, child and adolescent psychiatry, the psychiatry of learning disability and psychotherapy. Applications are made through regional deaneries, who advertise any vacancies in BMJ Careers. Training in a single specialty, leading to the award of a single certificate of completion of training, or CCT (formerly CCST), requires 3 years of training. Trainees undergoing training in the psychiatry of learning disability, general adult or old age psychiatry may spend one of these years in another appropriate specialty. Training in a combination of specialties (leading to a dual CCT), or in a lecturer post in a single specialty, requires 4 or 5 years, depending on the combination. The College's Higher Specialist Training Handbook (Royal College of Psychiatrists, 1998) outlines the requirements for specific dual CCT combinations. The number of regional specialist registrar vacancies is restricted by the availability of national training numbers. Vacancies depend upon existing specialist registrars completing their training and securing a consultant or locum consultant post, or moving to train in an additional sub-specialty, or the acquisition of funding for an additional national training number. Trainees can obtain helpful careers advice from regional higher specialist training programme directors, and by looking at any published regional ‘competition ratios’ (Whitehouse, 2002). In recent years, specialist registrar recruitment to general adult psychiatry has become relatively less popular compared with the psychiatric sub-specialties, possibly owing to the perceived increased workload for general psychiatry consultants without improved resources (Sims, 1997).

Specialist registrars wishing to transfer to another training programme in the same specialty should plan well ahead (Newlands & McKinna, 2001), liaising with the programme directors, postgraduate deans and likely future trainers. Although temporary geographical transfers (6–12 months), to gain specialist experience offered by another region, can be done with the trainees retaining their existing national training number, permanent transfers require allocation of a new number by the new region.

Wide regional variations exist for specialist registrars wishing to train flexibly, with some regions unable to fund all their flexible trainees. Over recent years, child and adolescent psychiatry in particular has seen a rise in the number of flexible trainees (Pidd, 2003).

Overseas doctors without UK residency rights can apply for fixed-term training appointments, which carry a fixed-term training number. These are categorised as ‘type 2’ specialist registrar training programmes.

Senior house officer training experience

In applying for specialist registrar schemes, trainees who have given some thought to higher training during their senior house officer (SHO) years can reap the rewards of any earlier work. Although gaining a broad clinical experience and passing the MRCPsych examinations are the priorities for most SHOs, they should also be encouraged to engage in other activities that might benefit their future career plans. This includes participation in audit projects, undergraduate medical student teaching, management meetings (involving service development or risk management), and learning basic computing and research skills (e.g. performing literature reviews). Educational supervisors should ensure that clear, focused education and training objectives are set at the beginning of each SHO placement. Each target should be realistically attainable, as the European Working Time Directive can considerably shorten SHOs’ available ‘training time’. Therefore, a trainee interested in a future career in a predominantly ‘organic’ branch of psychiatry (such as learning disability psychiatry, old age psychiatry and neuropsychiatry) could realistically:

1. • complete a regional audit looking at ‘off-label’ prescribing in old age psychiatry;

2. • lead seminars for medical students on the ‘physical theories’ of schizophrenia;

3. • perform a literature review on the use of antipsychotics for challenging behaviour in people with learning disability;

4. • contribute to a management meeting looking to develop a local protocol for the pharmacological treatment of challenging behaviour.

Trainees should aim to complete an audit cycle by either ‘closing the loop’ themselves or asking their successor to do so. Some trainees may be able to complete a small research project, either in an SHO research post or during their regional day-release course (if it doubles as a MSc course). However, for most SHOs participation in formal research is probably an unrealistic aim. Writing up an interesting case report or responding to published papers (by e-letters to journals) is more realistic. Writing e-letters can sharpen trainees’ critical appraisal skills, increase the chance of journal publication and provide a topic for discussion at the specialist registrar interview.

Use of the College's logbook allows an accurate, up-to-date record to be kept of the training experiences and competencies gained during basic specialist training. It can also make the hurdle of getting shortlisted for a specialist registrar interview easier to tackle.

Getting shortlisted

Most training programmes require the submission of a completed, detailed application form rather than a traditional curriculum vitae. The form usually reflects a locally agreed ‘competence framework’ (Heard et al, 2002), aimed at selecting future psychiatric specialists. Although its structure varies from region to region, certain information is requested in almost all specialist registrar application forms (Box 1). Referees are asked to complete a ‘structured’ reference form, in accordance with good recruitment practice (Weston, 2000). Shortlisting committees score each applicant on the basis of the information contained in the form, using a pre-determined score sheet, which identifies ‘ essential’ and ‘desirable’ criteria for appointment. A minimum score is needed to be invited for interview.

Trainees should read the guidance issued with the form carefully. Some sections of the form may need to be filled in using your own handwriting; in others, typed information may be acceptable (easier to do if the form can be downloaded from the Internet). Use your logbook to extract the salient points in your training that are relevant to the programme you are applying for. Describing an audit on urinary drug screening in a general adult ward might look impressive in an application for a general psychiatry scheme, but is less likely to stand out when applying for a learning disability scheme: quoting an audit on ‘out of licence’ prescribing might look better there. Some training experiences (such as teaching or examining medical students, computing skills and published e-letters) can be relevant to all training schemes.

Make sure the handwritten entries in the forms are legible, as copies are made for the interview panel to read through if you are successful at reaching the shortlist. Small handwriting in blue ink does not photocopy well! If typing any sections, use a simple sans-serif text, avoiding any fancy fonts or italics.

Properly completing an application form can take several hours. Compile a rough draft on a copy of the form, and ask your educational supervisor to look through it. Respond to any changes recommended before completing the actual form.

The interview

Specialist registrar interview panels in psychiatry can be daunting because of the number of panel members, who generally include:

1. • the relevant programme director (or directors)

2. • a deanery representative (usually the postgraduate dean)

3. • a representative from the Royal College of Psychiatrists

4. • a lay representative (who usually chairs the interview)

5. • a selection of current specialist registrar trainers (including a university nominee) from the relevant specialties.

Remember that most panel members are looking for potential future colleagues. A smart dress code, appearing relaxed and ‘politely’ confident and displaying an ability to answer questions in a diplomatic and balanced way can help to attain success.

Box 1. Generic information needed for most specialist registrar application forms

1. • Professional qualifications (with dates)

2. • Current and previous employment details

3. • Courses attended (can include MRCPsych, section 12 approval, life support and computing courses)

4. • Audit experience

5. • Teaching experience

6. • Information technology experience

7. • Management experience (including committee work)

8. • Presentations made at local, regional and national level (e.g. case presentations, journal clubs)

9. • Experience of evidence-based medicine

10. • Research experience (past and in progress)

11. • Prizes and publications

12. • Goals for specialist registrar training

13. • Three references (one of whom must be your most recent or current supervisor)

To ensure equal opportunity at any given regional interview, each candidate is asked the same set of initial ‘stem’ questions, with follow-up ‘ probe’ questions based upon their responses. The College's competency-based curriculum for higher specialist training provides an excellent guide for specialist registrars to the topic areas that are likely to be covered in the interview (http://www.rcpsych.ac.uk/traindev/curriculum/index.htm). Table 1 summarises the main competencies, with some suggested examples. Trainees can usually adapt these to suit their own intended career plans, by quoting specific examples (e.g., realistic research projects that could be completed during higher specialist training). Think about how you would like to spend your ‘special interest sessions’, ensuring that they relate to your intended career plans.

Table 1. Core professional competencies for specialist registrars in psychiatry

Competency	Example
Clinical	Training as a general adult psychiatrist with expertise in eating disorder
Professional	Practise autonomously and ethically, using authority appropriately
Education and teaching	Experience supervising, teaching and examining pre-MRCPsych trainees and allied health care professionals
Leader and teamwork	Provide specialist input within the context of a multidisciplinary team
Researcher	Contribute to the development and dissemination of new knowledge by participating in appropriate audit/research (e.g. developing a screening tool to detect eating disorder among medical in-patients)
Communicator	Maintain good therapeutic relationships with patients, carers and other professionals
Management and service development	Develop a new clinical service or teaching innovations in psychiatry

Trainees should be able to describe any memorable cases they have been involved with, together with cases they did not handle so well. Saying that you have never had difficulty managing a case is unlikely to impress the interview panel. As E. J. Phelps said, ‘The man who makes no mistakes does not usually make anything’!

Be aware of topical issues regarding the National Health Service (NHS), and how they relate to psychiatry. Examples include current NHS regulatory agencies (such as the National Institute for Clinical Excellence and the Commission for Health Audit and Inspection), clinical governance, revalidation, personal development plans and continuing professional development. Do not be surprised to be asked ‘broader’ questions requiring debate, such as the value of research in specialist registrar training, the benefits of audit to the NHS or controversies surrounding the consultant contract. Have knowledge of the mental health National Service Framework documents, the role of assertive intervention teams and the proposed changes to the Mental Health Act 1983. Think about where you see yourself in 5–10 years’ time.

Satisfy the panel members (who may have differing views), by giving balanced arguments, highlighting the points ‘for’ and ‘ against’. Advances in Psychiatric Treatment, Psychiatric Bulletin, BMJ, Hospital Medicine and Hospital Doctor are good sources of review papers on topical developments. In throwing you a ‘ clinical vignette’ to discuss, the panel are probably testing your thought processes and powers of reasoning rather than your factual knowledge; for example, how would you deal with a team member who is ‘ behaving inappropriately’ towards patients? Apply your MRCPsych clinical skills by thinking broadly along the lines of the bio-psycho-social model, incorporating immediate, short-term and longterm management (Naeem et al, 2003). Avoid extreme views or flamboyant management ideas. Most selection panels rank applicants on the basis of the interview, application form and references, with some schemes putting more weight on one or other of these components. The panel may discuss and alter rankings if any applicants have similar scores.

Practise for the interview by asking your educational supervisor or current specialist registrar to conduct videotaped ‘mock’ interviews. Modify your techniques in response to any constructive feedback.

What to do if you are unsuccessful

The reality for many SHOs wanting a specific, but sought after specialist registrar rotation is that they may be unsuccessful at their first interview. This is particularly likely for those who have just obtained the MRCPsych. Such trainees have a range of options available, which could help strengthen their application for a second attempt.

Look out for any advertised 6–12 months locum ‘approved for training’ specialist registrar posts in the region. Although such appointments are competitive, they have the advantage of eventually counting towards the CCT award upon obtaining a national training number, as they carry the same training elements as substantive specialist registrar posts. Alternatively, locum ‘approved for service’ specialist registrar posts, with locum pay rates, may be available, although these lack formal training elements and do not count towards the CCT award.

Discuss the availability of other posts with your rotation tutor, who could also help you refine your interview techniques. Taking another SHO post might allow you time to complete an audit project, or enhance your teaching and management skills (by attending relevant courses, instead of the regional MRCPsych course). A staff grade or associate specialist post would provide experience at a higher grade (including section 12-related work), but might lack formal training opportunities. A clinical research fellow post would allow a combination of specialist clinical and research experience, where the latter could be continued during higher specialist training. However, beware of opting for a post that bears little relevance to your intended specialty. Time spent in a clinical research fellow post in eating disorders might raise uncomfortable questions at a specialist registrar interview panel for old age psychiatry or learning disability! An extra 6 months in an SHO post in the intended specialty would have looked better.

Conclusions

The College is actively continuing to review the higher specialist training programmes in psychiatry. Debate continues about the possibility of having ‘ generic’ general psychiatry training awards for all trainees, new training programmes (e.g. in neuropsychiatry or addictive behaviour) and modification of the specialist registrar ‘research day’. Whatever changes occur over the next 5 years, the principles of obtaining a national training number will remain the same. Early planning, focused training and good careers advice are essential. Educational supervisors have a pivotal role in this. In applying for a specialist registrar scheme, try a little ‘ role reversal’ – what attributes would you look for if you were on the selection panel?