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A career in psychiatry is as challenging and rewarding if not more than other specialties. Psychiatry has traditionally been regarded as a specialty, which lacked the excitement and glamour of other specialties. Doctors usually perceive psychiatry as an easy option for those who fail to progress in other acute specialties. This is certainly not the case. Research suggests that one in four people experience some kind of mental health problems in the course of a year in the United Kingdom.(1) With the emergence of newer treatments, different specialties and sub specialties, a career in psychiatry has a great deal to offer in its own right with its holistic approach. Training in psychiatry in the United Kingdom starts from the under graduate level. Specialist training in psychiatry is divided into Basic Specialist Training and Higher Specialist Training. Completion of training would lead to award of the CCT (Certificate of Completion of Training) and allows working independently as a consultant. Currently there are about 3000 consultant psychiatrists from all specialities in the United Kingdom. The total requirement of consultants per year, to replace and to fill new posts, is approximately 250 to 300.(2) Psychiatry will be fascinating if you are a 'people' person, with a genuine interest in how other people think and feel. Other qualities that help are good communication skills, the personal strength to face the difficult problems patients tell about and an ability to like people. A psychiatrist must be a good detective; while they cannot actually read minds, they know the correct questions to ask to pick up the clues. Psychiatry can be challenging when treating patients against their and/or their families wishes and who are non-compliant. Some of the illnesses run a chronic course with remissions and relapses. Treatment resistance is not unusual. Violence and unpredictable behavior of the patients is seen at times especially with co-morbid alcohol and illicit drug use.
Training in Psychiatry in the United Kingdom starts from the undergraduate level. During the general training programme in a medical school one could choose an elective period in Psychiatry. Undergraduate training uses the problem based learning model, which helps to apply the factual knowledge in clinical setting. After graduation general clinical training as pre-registration house officer is mandatory. There are currently no pre-registration house officer jobs in Psychiatry. However with the advent of the foundation jobs, doctors can choose to have a placement in Psychiatry. This is a good opportunity for doctors to get exposure to different specialties and aids in decision making about their career. This is an attempt to reduce the number of drop-outs and to reduce the over all length of training.
Basic Specialist training in psychiatry is at the Senior House Officer (SHO) grade for a period of at least 3 years. This takes place in Royal College approved and recognized rotational training schemes. Rotational schemes are organized by postgraduate deaneries. There are twenty-one postgraduate deaneries across England and Wales. These jobs are mostly advertised in British Medical Journal. To apply candidates need to be eligible to get the registration of the General Medical Council (GMC). Overseas doctors outside the European economic area need to take Professional and Linguistic Assessment Board (PLAB) test to be eligible for registration with the GMC unless they fulfill the criteria for exemption. There has been a recent increase in the number of doctors wanting to train in Psychiatry. Selecting appointable candidates in a competitive interview does appointments for the training schemes. It might take up to a year to find a suitable post for overseas doctors after passing the PLAB test.(3) The aim of this training period is to learn essential clinical skills, gain factual knowledge and to pass the membership exams. In the initial twelve to eighteen months trainees will be placed in general adult and old age specialties. After twelve months of training, trainees are eligible to sit for part 1 of MRCPsych exam. After passing the part I, trainees can spend about six months each in as many specialties as are offered by the training scheme (See table 1). Trainees can appear for part II of the MRCPsych exam after completion of thirty months of basic specialist training. It is mandatory to have six months experience in either Child and Adolescent psychiatry or Psychiatry of Learning Disability to be eligible for the membership of the college. Table 1: Specialties offered by the psychiatry training scheme
Training is well structured. Trainees are required to attend regional MRCPsych course and would be released from clinical duties, one day a week to attend the course. There would be additional teaching sessions in the local hospital. This would include clinical case presentation and Journal clubs. Small groups and Balint group are held regularly. One-hour of supervision per week with the supervising consultant psychiatrist will be arranged. During the training period, trainees will be expected to have gained experience in the assessment of psychiatric emergencies, day to day management of patients, assessment and management of risk, prescription of medication, administration of electro-convulsive therapy, psychotherapy training, and use of the mental health act to name a few. Training promotes working in multidisciplinary teams and community teams. At the start of every placement, trainees will discuss and record the objectives and targets with the supervising consultant. This will be reviewed in the middle of the term for that post and an appraisal at the end of every placement SHO`s will be required to do on-call duties after working hours, keeping in line with the European working time directive. This is usually achieved by an on-call rota or partial shift system.
Membership exams are conducted by the Royal College of Psychiatrists. There are two parts to this examination; each includes a clinical exam, which can only be taken after passing the written test. Passing this exam enables one to be a member of the Royal College of Psychiatrists and is a requirement to progress in the career to do higher specialist training. Part 1 of the examination consists of a written paper comprising of Individual Statement Items and Extended Matching Items and a clinical examination in the form of Objective Structured Clinical Examination (OSCE). Part II of the examination consists of two multiple choice question papers, an essay paper, critical review paper and clinical exam. The clinical exam has three patient management problems and an individual patient assessment. The usual pass rate for each part of the exam is around 45 percent. There is no limit on the number of attempts.
The main aim of higher specialist training is to provide a doctor who has completed basic specialist training with an educational programme, which will fit him/her for the independent practice of psychiatry, whether as a consultant in the NHS or as a senior member of an academic department. Higher specialist trainees are referred to as Specialist Registrars within the National Health Service. There are four ways to enter the specialist registrar grade: CCT training programs, Fixed Term Training Appointments (FTTA), Locum Appointment for Training (LAT), Locum Appointment Service (LAS). The minimum requirement of the Royal College to apply for CCT or LAT are MRCPsych or college approved equivalent qualification (See table 2) and 3 years of approved Basic Specialist Training. Table 2: Requirements of the Royal College
Overseas doctors may be appointed to Type I or Type II higher specialist training programmes. Candidates who have one of the colleges recognized qualifications could apply for Type I pogramme. This will lead to the award of CCT. Those who are intending to obtain higher specialist training which will lead to the award of their specialist qualification overseas need to apply for Type II specialists registrar post (FTTA). Type II trainees will not be awarded CCT. Royal College has endorsed a number of dual CCT. Dual CCT is to allow trainees to train in more than one speciality for a period of four to five years depending on the combination. (See Table 3). The provisions of dual certificates are a matter for individual deaneries and are subject to the availability of training resources and opportunities. Table 3: Available dual CCT and their duration
In higher specialist training the focus shifts from knowledge to competence and performance based training to promote high quality of patient care. The training of a specialist registrar is flexible and he/she can tailor the programme to suit his individual interests and future aspirations. All trainees will have the opportunity to engage in clinical practice to a point where proficient independent practice can be achieved and will gain experience in management, teaching, participation in multi-disciplinary teams. The exposure to wide clinical experience and involvement in academic activities will enable trainees to undertake clinical practice informed by scientific and objective spirit. Trainees will be encouraged to develop the habit of self-directed learning, which will motivate a ready participation in Continuing Professional Development (CPD). Training in the chosen specialty lasts for at least twenty-four months. In the remaining twelve months, trainees can opt to work in a different specialty, for example a trainee in general adult psychiatry can opt to do a year in Forensic Psychiatry or Old Age Psychiatry. A common distribution of work (10 sessions in a week) is six sessions in the chosen specialty including academic time, two sessions of special clinical interests and two sessions for research. Special interest sessions can include experience in Liaison Psychiatry, Perinatal Psychiatry, Cognitive Behaviour Therapy or Forensic Consultation to name a few. The trainee will be encouraged to change his/her special interests sessions regularly to give exposure to a wide range of facilities. Special interest sessions will not figure in higher programmes in child and adolescent psychiatry. It should be understood that specialist registrar training is not an extension of SHO work and the specialist registrar will work more independently and has a more supervisory and managerial role. The trainee will be provided with access and tools required to pursue Research. They will be involved in Audit, teaching and management experience. All specialist registrars will be required to participate in out of hours on call rota with consultant cover. Psychotherapy specialist registrars are not required to participate in the on call rota. A training consultant will be available with time-tabled supervision, regularly. Towards the end of the placement both the trainer and the trainee write a report. An annual assessment of specialist registrars is central to the award of CCT. The main aims of these assessments are to monitor the progress of clinical, administrative and academic training including research. At the end of training in psychiatry for at least six years as outlined above, the trainee will be awarded the CCT and will be able to work independently as a consultant psychiatrist. Psychiatric training in the United Kingdom is a rewarding experience. The training is structured to gain knowledge and competence in core skills for the effective practice of psychiatry at all levels. There is immense interest and help to pursue audits and research and a growing emphasis on keeping upto date with the new advances in psychiatry. We have endeavored to provide a factual and concise account of the current training for psychiatry in the United Kingdom. An effort has been made to help give a clear introduction to doctors who aspire to train in psychiatry in the United Kingdom. However we must emphasize that this account is only an overview and doctors interested should be able to gain further details from the Royal College of Psychiatrists.
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We are grateful for help from: Dr. Magadi Gopalakrishna Harish (Specialist Registrar in Old Age Psychiatry), Dr. Prashanthi Veeramachineni (SHO in Psychiatry) and Dr. Venkat Sumanth Kumar for their suggestions
For further information: Royal College Of Psychiatrists, 17 Belgrave Square, London, SW1X 8PG(tel:00 44 (0) 2072352351: www.rcpsych.ac.uk) General Medical Council Regent’s Place, 350 Euston Road, London NW1 3JN(tel:0044(0) 845 357 8001: www.gmc-uk.org) |
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