Background and evidence for the scheme

Summary
“Psyched up for Medical School” is a scheme offering work experience placements to students applying to medical school.  We have so far supported 40 students locally and are in the process of arranging further programmes.  There is evidence that such schemes improve the likelihood of candidates subsequently applying to specialty training schemes, and work experience placements in Mental Health Trusts have been shown to reduce stigma towards Mental Illness.
We wish to extend the scheme in order to have a positive impact on applications to psychiatry as well as improve the calibre of applicants to medicine from lower socioeconomic groups.
Background
There is no shortage of articles bemoaning the problems with recruitment to psychiatry. I am pleased to read that in 2013 the Dean, President and Registrar for Recruitment at the Royal College of Psychaitrists reported that the recent recruitment drive had led to an improvement in CT1 fill rates (1) and the same trio encouraged further “initiatives to engage medical students…summer schools and taster sessions”. Perhaps this is leaving it a bit late, or at least not the most efficient use of resources.  A large study of postgraduate career choices, found that “inclinations before medical school” was particularly important in aspiring psychiatrists (2), which supports an earlier literature review which concluded that the College should focus on factors influencing career choice before and after undergraduate training (3). Colleagues in General Practice have recognised that a person’s personal experience of a General Practitioner has a greater effect on their attitude towards a career as a GP than the exposure to general practice in medical school (4).  Whereas most applicants to medical school will have consulted a GP, few will have met a psychiatrist and many will not even realise that psychiatry is a medical career.  We must be more proactive than the GPs and introduce potential doctors to real-world psychiatry before they enter medical school.   Despite the reported improvement in numbers, Professor Sir Simon Wessely states in his blog that “recruitment and retention (workforce and training)” remains the Council’s top priority for 2015 (5).
Another theme of publications in these journals is assessing stigma towards mental illness and suggesting schemes to reduce this. The Royal College’s Changing Minds campaign was unfortunately not as successful at reducing stigma as had been hoped (6), with the 16-19 age group being the group with the highest rate of negative opinions about mental illness (7).  I imagine that reducing stigma is at least one of the aims of the Council’s third priority for 2015- “Communication and engagement” (5) priority.
A major problem facing a subset of the group with the worst scores on the stigma-scale, the 16-19yr olds, is a lack of work experience placements for those applying to medical school. In 2005 96% of medical graduates reported having some form of work experience in the field prior to application (8) with 82% feeling that doing work experience was “very important” in order to secure a place at medical school.  With the increase in competition for places in medical school this number is likely to have increased.  The BMA have recognised that there is a lack of easily accessible work experience placements and that students with personal contacts in the medical profession are in a better position to arrange work experience and thus make a considered and credible application to medical school (9).  The Medical Schools Council have sought to address this in the PRACTISE scheme, which encourages work experience providers to prioritise work experience applications from students from a lower socio-economic background as part of the “Selecting for Excellence” project (10).
There are a number of local work experience schemes predating PRACTISE with a similar ethos, including the Medic Insight project in Edinburgh and Dundee (11), where potential medical students are offered placements shadowing doctors in a variety of specialties.  Last year, Kennedy and Belgamwar reported on their project to offer work experience placements across the field of mental health professions to A-level students and reported an improvement in attitude towards mental illness after the placement and a positive shift towards considering a career in mental health (12).  This is a very positive finding as it suggests that stigma towards mental illness may be addressed at this impressionable age by experience of the mental health sector.  However, it seems an inefficient way of improving recruitment to psychiatry specifically, given that only a small minority of those studying A-levels will consider applying to medical school, let alone go on to consider psychiatry.  Albert and Raoof responded to this study by recognising the lack of availability of work experience placements in Mental Health Trusts across the UK (13).
We have devised a scheme to address these issues (recruitment to psychiatry, stigma towards mental illness, and lack of work experience placements for students applying to medical school), which ties in with the College’s priorities for 2015 (5).
We propose to increase the number of work experience placements in Mental Health for students applying to medical school, in particular pro-actively seeking out students from less advantaged backgrounds. Co-ordinating this nationally will aid Mental Health Trusts in complying with the MSC’s PRACTISE commitment to improving access to work experience and will reduce the burden of administration and standardise opportunities. Such a scheme is likely to reduce stigma in a cohort from a particularly key age group and our hope would be that a positive message about mental health would be spread organically by the students talking to other 16-19 year olds about their experience of their work experience.  Finally, a positive experience of a specialty prior to undergraduate training has been shown to have a positive impact on later career choice (2), (3) so our hope would be that this would have a later positive effect on recruitment to psychiatry.
We have piloted a scheme in Oxford Health NHS Foundation Trust to proactively offer work experience placements to local sixth form students considering applying to medical school.  We then support the students in becoming “Mental Health Ambassadors”, raising awareness of Mental Health issues and reducing stigma amongst their peers.  We have evaluated and adopted the project, created a “franchisable”how-to guide, and are running a third scheme in a few months’ time.
Psyched Up for Medical School
A full step-by-step guide to running the scheme is available on request. In summary, the scheme has been launched by two Specialty Trainees, the Director of Medical Education, and part-time admin support.  A short leaflet about a career in psychiatry and application forms for the scheme are sent annually to heads of sixth forms at local schools who distribute them to any student applying to study medicine in the UK.  The application form requires students to write a brief personal statement and to seek endorsement from a teacher and parent/guardian.
Applications received are screened and, where appropriate, applicants are offered a work experience placement.  Most applicants are in Year 12 (aged 16-17) and can only embark on work experience once they turn 17, hence a number of programmes are run through the year, coinciding with school holidays and no one programme is overburdened with applicants. Doctors of all grades are recruited through emails, presentations at meetings and word of mouth to offer time slots in the programme weeks when they would be happy to have a student shadow them; doctors in training are encouraged to discuss this with their supervisor before committing. Doctors offer time slots ranging from half a day to a full week. Placements are not offered in Forensic Psychiatry or Child and Adolescent Psychiatry due to risks and potential confidentiality issues respectively.
A timetable for each student is arranged, with day and half-day clinical placements across a range of settings for at least 3 days of the week.  The student completes further forms in order to be issued an honorary contract for the trust; the risk assessment for this contract states that the student is able to have clinical experience but should be supervised by a professional at all times.  Prior to starting the placement, SB calls the students to finalise arrangements and introduce herself as a point of contact through the week for practical and pastoral issues.
On the Friday of the week all students join together for a series of presentations and case discussions from specialties not represented in the placements, information about academic psychiatry and current research, reflective discussion of their experiences of the week and the opportunity to present a case to the group.
Preliminary results
  • 97% of students feel they have a better understanding of Mental Illness following the scheme
  • 75% students are more likely to consider a career in psychiatry following the course (the other 25% said they were “as likely” to consider psychiatry after the course as prior to the course and many of these had already stated a preference for a career in psychiatry).
Qualitative data themes:
Awareness of mental health problems increases and stigma decreases:
“Seeing a variety of patients with varying mental illnesses improved my understanding of psychiatry and mental health”
“The experience let me know psychiatry is not as terrifying as I thought”
“I’ve now become aware of how “human” people with mental health (sic) are.”

“My “stereotypical” view of psychiatry changed and I believe there should be as much respect and value to psychiatrists as any other doctor”.

“I now know that…people with mental health illnesses are not people who are hopeless cases. There is help for them and we shouldn’t give up on them”.
“I have realised that [mental illness] is much more prevalent and affects lots of people and manifests in very different ways”
“I thought mental illness is very serious. I didn’t think that there could be different levels of mental illness.  Also, the patients with mental illness are just as normal as other people”.
“ [I now know mental illness]… is a medical condition which people didn’t choose to have and can affect absolutely anyone.
Attractive aspects of a career in psychiatry:
The variety within psychiatry, the amount of patient contact and the opportunity to improve lives were seen as positive aspects of a career in psychiatry:
“It has a much greater variety than many other specialties- you will NEVER get bored.”
“[You] have the chance to listen to different people’s stories about their lives”.
“Very rewarding knowing you can really change someone’s lives (sic) in all aspects”
“everything is not black and white”
Many students were surprised by the role of the multi-disciplinary team in a psychiatrists work:
“Seeing how team work plays a huge part in psychiatry [surprised me]”
“I always thought that psychiatrists tend to have a 1-1 relationship with their patients but indeed they don’t – they work as a team!”
Less attractive aspects of a career in psychiatry
Despite on the whole students being pleasantly surprised how “human” the patients they encountered were (see comment above), some stated that “dangerous patients” were a downside to a career in psychiatry:“I found some of the clients that I have seen a slight bit intimidating”

The emotional resilience required for the specialty was also highlighted:
“It could sometimes be depressing and tiring when you tried to understand the patient’s pain and sadness in their lives.”
“I would find it hard to hear about how many people feel suicidal”
Other negatives reported were “lots of paperwork”, “long hours” and “extensive legal requirements”.
Informing career choices
The students valued the “real life” experience of shadowing doctors.
“It was a great insight to the daily life of a doctor. I learnt a lot, not only just about psychiatry but being a doctor in general”
“I did not know how busy a psychiatrist could be”
This experience, for some, confirmed that they wanted to study medicine:
“[I’m] much more confident about applying to medical school”
and, of one of the doctors who was shadowed: “I thought Dr X was an amazing doctor and man. He definitely made me believe a career in medicine is what I want to do”.
For many it made them more interested in a career in psychiatry:
“It made me realise that this is 100% what I want to do”
“I was already considering psychiatry as a career path but I now feel much more excited and enthusiastic about it”.
“It has made me seriously consider whether or not I’d like to do this.  Many parts were truly fascinating and are really influencing my decisions.”
For a few others, the experience led them to believe that psychiatry may not be the right career for them:
“I don’t think my mental state is strong enough to be able to deal with a career in psychiatry”
“I don’t think I would go towards this in the future but I do find it intriguing now and will explore it in a little bit more depth”
However, these students wanted to make sure we realised the experience had been useful, despite them deciding against a career in psychiatry:
“I’m sad to say I don’t think I will be pursuing a career in such a field….but I am now more sure of what specialty I am looking for”
“Please don’t think I think this was a waste of my time because I have mentioned my disinterest in psychiatry- the day was very helpful.
Our results cannot claim any longterm benefit to the students or to recruitment to psychiatry. However, considering Kennedy and Belgamwar’s results of a similar project (12), it is likely that the experience will have reduced the students’ negative attitudes towards mental illness.  Also, the project goes some way towards raising awareness of psychiatry as a medical career choice at a pre-undergraduate level, and therefore, hopefully, will have some positive impact on subsequent career choice, as suggested by Goldacre(2) and Brockington(3). Long term follow up of the cohort who have had the placement would be feasible and it would be interesting to see in 8 years’ time if the work experience has any bearing on their career choices.  However, at present the sample size would be too small and self-selected to draw any firm conclusions.
Although we did not formally collect data about the background of students applying, 8 of the 9 students on the week course did not have a close relative in the medical profession and none of them had arranged any other work experience placements.  This suggests that our proactive approach of advertising to local schools is successful in identifying students who would otherwise perhaps struggle to arrange work experience placements.
We are currently collecting more data with regards to the students attitudes towards psychiatry
and will follow the students up to see how the scheme impacts on later career choices.
Plans for the future
As we continue to expand locally, news has spread to students living in other areas and we have had applications for the programme from students well outside of the Trust and Deanery.  This suggests that there is a gap in the market for well organised work experience placements, particularly for those students who struggle to find placements through family and friends.  We believe that if Mental Health Trusts were to fill this gap in the market it would be fulfil a need specifically articulated by students, it would help trusts to comply with the MSC’s PRACTISE guidelines (10) and would help to reduce stigma towards mental illness in a key age group plus increase awareness of psychiatry as a career choice, which we hope will lead to improved recruitment at CT1 level in years to come.
The Royal College is already supportive of work experience placements in psychiatry (14) but this has not yet been translated into tangible improvements. We would be keen to help other Trusts set up similar programmes in other areas of the country and can provide the necessary framework and paperwork. We envisage starting further schemes in other Trusts as an extension of this pilot project and would hope that eventually the scheme would be easy to run nationally from one centre.
Given the huge number of applicants to preclinical medicine (in 2013, 84395 applicants for 7515 places (15)) it would not be feasible to offer every applicant a work experience placement, given there are only 51 Mental Health Trusts nationwide (16). We would hope that by requesting the schools endorse all applicants to the programme and reinforcing the message that the placements are a limited resource we will minimise the risk of accepting applicants who are unlikely to be offered a place in medical school.  Still, the numbers of credible applicants are likely to exceed the potential number of work experience placements.  It would therefore be prudent to focus on compliance with PRACTISE guidelines and targeting applicants who would otherwise not have the opportunity to do work experience.  It is difficult to calculate how many students this might be; BMA figures from 2009 state that 15% of students accepted to medical school came from the lower 4 socioeconomic classes (17); this accounts for about 1000 applicants, which could be easily accommodated for work experience purposes in the 51 Mental Health Trusts (approximately 20 students per Trust per year).  Thus, the proposed eventual extension to this project would help encourage students from under-represented backgrounds into medicine, as well as addressing College priorities of improving recruitment to psychiatry.
We would hope that as we grow a cohort of students progressing through the scheme and fulfilling the Mental Health Ambassador roles, recruitment to psychiatry will improve, as well as stigma towards Mental Illness reducing in this key population of 16-19 year olds.
References
(1) Burn W, Bailey S, Brown T.  Recruitment into psychiatric training- positive change. Psychiatric Bulletin 2013 37:277
(2) Goldacre MJ, Fazel S, Smith F, Lambert T. Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009.  BJPsych 2013 202:228-234
(3) Brockington I, Mumford D. Recruitment into psychiatry. BJPsych 2002; 180: 307-312
(4) Henderson E, Berlin A, Fuller J. Attitude of medical students towards general practice and general practitioners. British Journal of General Practice 2002; 52: 359-363
(5) http://www.rcpsych.ac.uk/discoverpsychiatry/thepresidentsblog1.aspx
(6) Smith M, Anti-stigma campaigns: time to change. BJPsych 2013 202: s49-s50
(7) Crisp A, Gelder M, Goddard E, Meltzer H. Stigmatization of people with mental illnesses: a follow up study with the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry 2005. 4 (2) 106-113
(8) Park J, Philipp R, Hughes A. Do we value work experience before medical school? British Journal of General Practice 2005 242-243
(9) https://bma.org.uk/news-views-analysis/news/2014/december/bma-backs-campaign-to-widen-participation-in-medicine
(10) Selecting for Excellence. End of Year Report 2013. Medical Schools Council
(11) Hunter N, Shah A, Bollina P. Improving medical work experience for students. The Clinical Teacher 2010; 7:284-287
(12) Kennedy V, Belgamwar RB. Impact of work experience placements on school students’ attitude towards mental illness. Psychiatric Bulletin 2014 38: 159-163
(13) Albert A M, Raoof A. Availability of work experience placements in psychiatry: the real picture. Psychiatric Bulletin 2014; 38(6): 306
(14) Mynors-Wallis L. College Position Statement Work Experience in Psychiatry. RCPsych 2012
(17) BMA Equal Opportunities Committee. Equality and Diversity in UK Medical Schools British Medical Association October 2009