Career Choice

Training and education in geriatric psychiatry are influenced to a considerable extent by factors related to career choices made by medical graduates in general. In the United States, Bragg and Warshaw reported that problems persist in recruitment and retention of ‘high-quality USMGs’ (United States Medical Graduates) in both geriatric

ⁱOld Age Psychiatry is recognised in the UK by the Postgraduate Medical Education and Training Board as a subspecialty, carrying its own Certificate of Completion of Training.

medicine and geriatric psychiatry. They identified early exposure to geriatrics as an important factor in selecting it as a career³, as did Lieff et al., who investigated more fully which particular experiences showed a positive effect: they mention specific teacher attributes, training experiences, personal experiences with seniors, and the medical, neuropsychiatric and multifactorial nature of the field⁴. Similarly, in the United Kingdom, McParland et al. showed how undergraduate experience is essential in choosing the specialty and the more so if that experience is positive and of a high quality⁵.

There are other, related factors at play with regard to career choice: Goldacre et al. report that in the United Kingdom non-white consultants who qualified abroad were at 18.4% significantly over-represented in geriatric psychiatry⁶. This pattern of skewed ethnic representation can be recognized in general in British psychiatric training: in his recent newsletter the Dean of the Royal College reported that at the last sitting of the final membership examination (the so-called Clinical Assessment of Skills and Competencies) only one out of eight candidates was a UK graduate⁷.

It is therefore clear that the UK remains a net importer of doctors, and this pertains to geriatric psychiatry even more than to some of the other psychiatric subspecialties. He believes that two important explanatory factors can be found in ‘the current dismal experience of many medical school clinical attachments’ and ‘the poor penetration of psychiatry into the Foundation years’ (the British version of post-qualification, pre-registration training). One could therefore conclude that even in the UK there are major difficulties in recruitment and retention in psychiatry (and therefore in geriatric psychiatry), regardless of the fact that internationally the UK could be regarded as advanced in its development of geriatric psychiatric services and related training and education.

Service Provision

Surveying the international picture of education in old age psychiatry, it soon becomes clear that it appears mature and sophisticated in those countries where psychogeriatric services exist, which themselves are mature and established. On the contrary, education tends to be poorly structured, educationally isolated and occurring in an ad hoc fashion in those countries where psychogeriatric services are either non-existent, or are an ‘afterthought’ featuring in other medical specialties.

In 2001 the World Psychiatric Association (WPA) section on old age psychiatry surveyed the level of development of medical education in geriatric psychiatry in 93 countries. A total of 48 countries responded, which in itself at 52% was a worryingly low response rate – even for a postal questionnaire – given that the survey was particularly aimed at those clinicians who were known to have a special interest in and affinity to the subspecialty. Of the responders, 40 countries reported the existence of old age psychiatric services and 44 formal teaching at undergraduate level, but only 13 full recognition of the discipline as a subspecialty. The member societies furthermore considered support for the development of postgraduate training as their most pressing need⁸.

In those countries where there is a drive to develop both services and education, there is often the problem of how to tackle the ‘chicken and egg’ phenomenon: it is, perhaps predictably, quite difficult to get education going when clinically there is no defined basis for that to occur in, although it must be pointed out that in the case of geriatric psychiatry some lessons have been learned from geriatric medicine. The same survey found that chairs in geriatric medicine – as a reasonable indication of structured advanced educational activity – only exist in countries where geriatric medicine is recognized as a subspecialty. This appeared not to be the case for geriatric psychiatry; several countries reported chairs in geriatric psychiatry to be in existence, even when the discipline was not yet formally recognized.

Subspecialty Recognition

The process of developing services when there are only a few appropriately skilled and motivated medical specialists pushing the psy-chogeriatric agenda is understandably a laborious exercise. But even when there are such interested parties present, the response from the wider professional body may be felt to be less than supportive. For example, in Canada Herrmann⁹ pointed out that there exists a very active geriatric psychiatric subspecialty. The Canadian Academy of Geriatric Psychiatry counted in 2004 more than 190 members and organizes annual academic meetings, residency training programmes, numerous undergraduate and postgraduate training programmes and fellowship awards. It developed the Canadian Coalition for Seniors’ Mental Health (CCSMH), which – among many activities and initiatives – co-hosted and organized the 9th Congress of the International Psychogeriatric Association. Yet the Canadian Royal College of Physicians and Surgeons did not demand any particular clinical and training time requirement in geriatric psychiatry until 2008, when it incorporated a mandatory six months’ placement in geriatric psychiatry into its junior residency training programme¹⁰ and to this day it does not recognize geriatric psychiatry as a sub-specialty, while it does list geriatric medicine as such¹¹. Hermann points out that such subspecialty recognition is vitally important to ‘strengthen the awareness and profile of geriatric psychiatry, increasing the likelihood of recruitment into the practice’. If such recognition is not forthcoming in a country such as Canada, then how difficult will it be in countries that do not feature highly regulated professional bodies and training accreditation processes?