Recruitment from foundation year 2 posts into specialty training: a potential success story?

Summary

This paper examines the characteristics of a foundation year 2 post in psychiatry from the Leicestershire, Northamptonshire and Rutland foundation programme, where all three of the trainees who occupied the post in its first year were successfully appointed to specialty training posts in psychiatry. We discuss the potential strengths of foundation posts in psychiatry as a possible recruitment aid into specialty training in psychiatry in the UK.

Psychiatry foundation programme

The 2-year foundation programme in the UK went ‘live’ in August 2005. It was developed from the proposals published in Unfinished Business ¹ and Modernising Medical Careers. ^2,3 Postgraduate deaneries and later the newly developed foundation schools within deaneries were charged with the task of creating 2-year foundation programmes (FY2), with the first year of the programme (FY1) equivalent to the old pre-registration house officer year. Educational aims of FY2 are to develop generic competencies as well as focusing on the acquisition and development of skills in assessment and management of acutely unwell patients across a range of seven acute care scenarios, one of them being psychological and behavioural problems. ⁴

Experience would be gained in three 4-month placements across a range of specialties, including general practice. ³ Doctors wishing to pursue a career in psychiatry have the opportunity to develop general clinical competencies outside psychiatry before entering core specialty training. For doctors with clear career intentions outside psychiatry the acquisition and development of skills in detecting and managing psychiatric disorders, a greater understanding and awareness of patients’ psychological reaction to illness, as well as destigmatising psychiatric patients, can only enhance their professional development early in their careers. ⁵ In addition, some doctors with uncertain career plans could gain exposure to psychiatry in FY2 and consider it a possible career option. These posts could be powerful recruitment aids into specialty training.

Leicestershire, Northamptonshire and Rutland foundation programme

At the time of the commencement of the foundation programme in August 2005 there was only one FY1 post in psychiatry within the Leicestershire, Northamptonshire and Rutland Foundation School. This post had been established several years before and attracted a self-selected group of doctors who intended to pursue a career in psychiatry. The FY2 post identification and development as well as training of educational supervisors was led by a consultant psychiatrist working as a foundation programme director within the Foundation School.

Foundation programme setting

An attempt was made by the Foundation School to identify posts which showcase psychiatry across a range of clinical settings, with experienced and enthusiastic supervisors who had been consistently highly rated trainers by basic specialty trainees in the past. Three of the FY2 trainees who passed through one of the seven posts in the first year are now in specialty training in psychiatry. At the beginning of the year the trainees were not expressing a definite preference for psychiatry. This paper examines the characteristics of the post and trainees’ opinions.

Psychiatry foundation post

The FY2 post was based in a district general hospital old age psychiatry purpose-built unit, which provides an in-patient, day and community functional and organic psychiatric service. The unit was adjacent to a general psychiatry in-patient unit and the FY2 doctor participated in the generic on-call rota. Senior medical input to the posts was provided by two consultant psychiatrists sharing a full-time clinical post; both had additional non-clinical responsibilities. The clinical responsibilities were largely based within the in-patient unit. There was no fixed or regular out-patient commitment but there was an opportunity to accompany senior doctors on assessments with eventual independent community and out-patient assessment before the end of the 4-month post for trainees.

Trainees

Two of the three FY2 trainees in the Leicestershire, Northamptonshire and Rutland foundation programme were female; two were graduates from the local medical school. One of the trainees had a strong interest in pursuing a career in psychiatry on entry to medical school; however, a less than satisfactory undergraduate block had raised some doubts about this option for them. The other two trainees had unclear career intentions at the beginning of the FY2 year but wished to explore psychiatry as a possible career option, and specifically chose a FY2 programme which included a psychiatry post. One trainee wished to pursue a career in a specialty which could provide a good work–life balance. All trainees valued the support and advice provided by the consultants in the post, especially the one-to-one relationship with an educational supervisor and protected 1-hour weekly educational supervision.

Assessments and trainees’ comments

All workplace-based assessments performed in the post were done with one of the two consultants. This was reported by the trainees to be in stark contrast to the experience of workplace-based assessments in non-psychiatric specialties, usually performed by less senior doctors, with feedback and formative learning less robust.

All trainees felt they were contributing to a team providing holistic care to patients, in contrast with ‘conveyor belt hospital medicine’. They thought that robust clinical and educational supervision had allowed them to develop increasing confidence and clinical skills. They found the uncertainty surrounding specialty selection into run-through training via the Medical Training Application System (MTAS) in early 2007 particularly distressing. However, all trainees felt well-supported at this time.

Two trainees had applied for a psychiatry post in round one; the other one applied in a subsequent recruitment round. All were successfully appointed to specialty training in psychiatry.

Trainers’perspective

Both consultants were enthusiastic about the challenges and opportunities relating to a new type of trainee. The posts had previously been occupied by more experienced doctors, usually with at least 6 months’ experience in general adult psychiatry; the trainers recognised that the FY2 trainee would require very robust clinical supervision and support, particularly in the initial weeks on starting the post. Consultants could quickly recognise the abilities of all three trainees as doctors. They all appeared to possess the personal qualities required of a potential psychiatrist, including excellent interpersonal, communication and empathic skills. Both trainers were involved in the workplace-based assessment process believing this to be a meaningful learning experience for the trainees. They agreed that this activity requires considerable additional time on top of weekly 1-hour educational supervision.

To facilitate recruitment into specialty training in psychiatry, the FY2 trainee would need to be exposed to different clinical areas within the specialty. ‘Tasters’ were arranged for the trainees across the range of clinical areas, including visits to the local therapeutic community, forensic psychiatry and general adult psychiatry including the crisis resolution team. The 4-month placement felt brief as the trainees’ development used to be measured over 6 months in the past.

Without a doubt, the greatest challenge over the 12-month period of the first year of having an FY2 trainee was the parallel process of the national specialty selection (MTAS). All trainees became distressed and required sensitive support in what was a very uncertain and ever-changing situation. The two female trainees faced the challenge of specialty choice and geographical location to consider balancing career against family and relationship issues. This resonated powerfully with both trainers as working mothers who had faced similar challenges at earlier stages in their careers.

Discussion

Factors that influence trainees’ career choices

Recruitment into specialty training in psychiatry among UK graduates appears stable at 4–5% between 1974 and 2000. ^6–8 Early undergraduate experience in psychiatry appears to be an important influence in long-term career choice – positive experience of psychiatry as an undergraduate has been cited by two of the three trainees. This would support the potential strengths of the foundation programme as a powerful recruitment aid into specialty training in psychiatry.

Further early and positive exposure after qualification has had a powerful effect in encouraging three doctors with uncertain career intentions to pursue specialty training in psychiatry. Important factors that appear to have had a positive influence here included the professional and personal development provided within a one-to-one supervisory relationship, encouragement and support from consultants during MTAS, seeing patients responding positively to treatment and increasing direct involvement in patient care as the post progressed. Career intentions to pursue psychiatry appeared to be influenced by the FY2 placement.

Role models and other factors important for female trainees

Two out of three of the FY2 doctors described here are female. It has been suggested that women have a greater aptitude for psychiatry as a specialty. ⁹ Both female trainees identified the trainers in the post as positive role models; neither had previously worked with a female consultant. ¹⁰ They cited family and lifestyle issues as important factors in their choice of future career. ¹¹ Such factors will become increasingly important with 60–65% of medical undergraduates being female. With an already higher proportion of female consultants in this specialty, psychiatry should be well placed to respond to the feminisation of medicine, particularly as positive role models of the same gender appear to enhance recruitment. However, the challenges of an increasing female workforce in medicine generally and in psychiatry specifically, particularly if women wish to work as doctors and have a family, require the urgent attention of the government. ¹²

Impending change?

In the recently published Modernising Medical Careers inquiry report, ¹³ Sir John Tooke called for the uncoupling of FY1 and FY2, starting in 2009. Paradoxically, the report acknowledged that the introduction of the foundation programme had gone well. The inquiry recommends that a themed FY2 forms the first year of one of four broad-based core specialty training stems. Although this may allow greater flexibility for doctors uncertain of their final career intentions, the decision to abolish the foundation programme appears premature.

Inclusion of psychiatry posts within the early years of postgraduate medical training can facilitate recruitment into specialty training in psychiatry. What appears to be required is better and early career advice, a systematic approach to identify medical students who possess the personal qualities that predispose them to the psychiatric profession, and accurate data in the form of strategic workforce planning figures to inform career aspirations and early choices of young doctors to ensure that an increasing number of UK graduates could enter specialty training. The Royal College of Psychiatrists and the newly formed schools of psychiatry will need to work closely with trusts and medical schools to ensure that the brightest and best can potentially be attracted into specialty training in psychiatry. In addition, it may also be appropriate to consider the use of the most experienced and valued trainers to facilitate recruitment from these posts.

Declaration of interest

A.M.B. was a Foundation Programme Director for Psychiatry until December 2008.