How to work in psychiatry

Behind misunderstandings and stigma attached to psychiatry, there is a fascinating and rewarding career to be found, write Dr Liz Ewins and Dr Dan Hodgson.

What it's all about

Life as a psychiatrist is incredibly diverse. It involves the prevention, diagnosis and treatment of mental disorders through a mixture of inpatient, outpatient and community work; visiting people in their own homes or residential homes, as well as liaising with medical wards and sometimes prisons.

Patients can have a huge range of complaints, from depression, bipolar affective disorder, schizophrenia, eating disorders, anxiety disorders, post-traumatic stress disorder, dementia and drug and alcohol abuse. The management of these problems is equally varied, including medication and occasionally physical treatments, such as ECT, but there is also a great emphasis on psychological treatments. Sometimes patients have no insight into their illness, which can require assessment and treatment by a psychiatrist under the Mental Health Act.

Psychiatrists work together with a team of mental health professionals, including nursing staff on the wards, as well as community psychiatric nurses, psychologists and psychotherapists, social workers, pharmacists and occupational therapists. The psychiatrist works across a patient’s lifespan, from birth to old age, and it can be a privilege to hear in detail about people’s lives. Attention to detail and excellent communication skills are essential in order to obtain the necessary information required to make a diagnosis and initiate treatment, as there are few diagnostic tests available in psychiatry. This is all done on a solid background of medical training, which the psychiatrist draws upon to tease out physical and mental health problems. 

The psychiatrist works across a patient’s lifespan, from birth to old age, and it can be a privilege to hear in detail about people’s lives.

LIFE AS A PSYCHIATRIST

The big draw of psychiatry is that you have the flexibility to make what you want of it. You can choose to specialise in a field of psychiatry that interests you, and within that specialty, you can choose the way in which you would like to work, such as whether to undertake inpatient or outpatient work. It is one of the few remaining specialties where there is a combination of neurosciences, general medicine, psychology and psychoanalysis. It is this fascinating variety that makes psychiatry such an exciting and intellectually challenging area to work in.

SUBSPECIALITIES

General adult psychiatry

This is the largest of the faculties and includes a range of specialties involved with the provision of psychiatric care to adults of working age. This involves inpatient as well as outpatient and community work, and specialist teams, such as the early intervention team, which responds to first presentations of mental health problems involving psychosis, and crisis teams, who deal with psychiatric emergencies and gatekeep admissions, plus aid patients once they are discharged. Other areas of adult psychiatry include psychiatric liaison, which is a service that provides psychiatric treatment to patients attending general hospitals, whether they attend outpatient clinics, emergency departments, or are admitted to medical wards.

Addiction psychiatry

This involves the assessment and treatment of people with complex medical and social needs arising out of addictions or addictive behaviour, which may include gambling. Substances may include alcohol, illicit drugs, prescribed or over-the counter medication, and volatile solvents. There are a range of treatment options, including psychological and pharmacological treatments, which may include drug substitution or detoxification regimes.

Old age psychiatry

This comprises the treatment of mental health problems in people aged over 65. This is where a psychiatrist’s medical background is most needed due to the co-morbidities and polypharmacy that are common in this age group.

As well as the mental health problems that are cared for in general adult psychiatry, organic psychiatric problems, including dementia, also make up a large percentage of the workload. When managed well, these challenging presentations can have a positive outlook for both patients and their families.

Child and adolescent psychiatry

This involves the diagnosis and treatment of mental health problems affecting young people and their families. There is a large emphasis on psychological treatments. Some of the commonly encountered problems in this age group are behavioural problems, eg ADHD and eating disorders. A real difference can be made to the lives of young people and their families, with the hope that difficulties can be managed and not go on to persist through the young person’s life.

Intellectual disability

This includes the diagnosis and treatment of mental health problems for people with learning disabilities. It can include the diagnosis and management of people with autism and Aspergers, as well as physical health complaints, such as epilepsy.

Psychotherapy

This encompasses a huge and developing range of psychotherapeutic practice within psychiatry.

Forensic psychiatry

This area helps people who have a mental disorder who present a significant risk to the public. It includes assessing and treating mentally-disordered offenders, investigating complex relationships between mental disorder and criminal behaviour, and working with criminal justice agencies to support patients and protect the public.

TRAINING

Following foundation training, or equivalent, you can enter specialist training in psychiatry. This begins with three years of core specialty training (CT1-3 posts). Generally, posts last six months with an emphasis on general adult psychiatry but flexibility within training posts means you can experience a wide range of subspecialties. During this time, you work towards obtaining your membership examinations.

After successful completion of three years of core training, you can then choose a subspecialty for higher training. This usually takes a further three years (ST4-6 posts). There is the opportunity for trainees to take time out of their programme to complete research if they wish to, or they can choose to “dual train” in two subspecialties, eg forensic psychotherapy. Following completion of higher training, trainees are able to apply for consultant posts.

Trainees are protected, and posts are geared towards training needs as far as possible. Supervision is in the form of weekly one-to-one sessions with a consultant, as well as Balint groups, which are spaces to talk with colleagues about clinical issues and cases that have made an impact on you. Research, teaching and management are all strongly encouraged, with time set aside for trainees to pursue these interests.

Specific academic posts are available within the training, which include more time away from ward duties in order to complete research. There is a considerable amount of research going on in psychiatry, which makes it a rapidly developing and evolving specialty, with new medications and approaches being churned out regularly, so there is real scope to make a difference and develop your own practice.

Trainees usually participate in an on-call rota, where they may be involved in assessing psychiatric cases on presentation to the emergency department, as well as admitting them and then managing their physical and mental health. This is again well supported by senior psychiatrists and a lot of assessments are done jointly with experienced community psychiatric nurses.

FIND OUT MORE

Arrange taster days, to gain experience. There are plenty of friendly and approachable psychiatrists who will be happy to let you shadow them. There are also opportunities to undertake a four-month psychiatry post as a foundation trainee.

For more information have a look at the Royal College of Psychiatrists website training page. 

The best bits:

• Psychiatry is rewarding and time spent with patients can be fun
• You get to know patients and there is a high level of continuity of care
• There is one-to-one supervision and a high level of support
• Flexibility and extra time for research, teaching and management
• Excellent work–life balance.

The worst bits:

• Exams
• Dealing with very unwell patients can be stressful.

What attributes do you need?

• Enjoy working with and be interested in all sorts of people
• Excellent listening and communication skills and the ability to emphasise
• An ability to work well as part of a team, and to take a leadership role when needed
• Patience and the ability to remain calm under pressure
• An ability to deal with uncertainty
• Well balanced with a good sense of humour.