In the psychiatrists’ chair

I have an odd ‘lived experience’ as a learner which in part represents an intersectionality between race, age and disability.

Tomorrow, some members of the Royal College of Psychiatrists appear to be rushing through some proposals to improve diversity in their College. I don’t want to mis-convey the original plans, but a summary of them I believe is here.

This is of course entirely laudable as a goal, but clearly the ‘rush job’ raises alarm bells for anyone. As a member not of that parish, I do find their approach very odd – a sort of ‘command and control’ without much command or control. Unsurprisingly, it has been subject to Twitter debate, which is generally a bad idea until proven otherwise.

My first foray into stigma came by reading Scambler’s sociological work on stigma and otherwise. That’s when I decided that ‘otherness’ tended to be a bad tide, and separating people largely ended up being segregation not divisive. I always had problems with the term ‘living well with dementia’, because I kept on thinking about those unfortunate individuals (and carers) who weren’t living quite as well. Segregation lies on a slippery slope for me with prejudice and stigma. A new stream for ‘postnomials’ is a bit of a no no in this regard?

So it came as a surprise to me that the Royal College of Psychiatrists was having ‘labour pains’ over the issue of their International graduates and SAS doctors. This issue is not unique to them – all Royal Colleges have similar issues. The regulator, General Medical Council, and Medical Schools Council have made it clear that active inclusion is meant to be the ‘norm’, and indeed for accreditation for Advance HE and the Academy for Medical Educators inclusion is taken as red.

Strategic leadership is valued in healthcare education, and no less important than in mental health and psychiatry. It’s worth reminding ourselves of theme 2 of ‘Promoting excellence‘ from the GMC. The GMC is paid for, and serves, registered doctors in the UK, so will only in part apply here depending on the interpretations of RCPsych.

Inclusive and diverse learning environments result in a better education for medical students and doctors. They can also lead to patients receiving higher quality andcompassionate care. Inclusion in an educational context is the facilitation of learning through pedagogy which allows for the differences between all learners. Inclusive practices are felt to include typically recognising uniqueness and promoting belongingness. Diversity is a fundamental property of populations qnd not a “problem” to be fixed. Equity addresses ongoing injustices experienced by marginalised persons, and leads to the construct that improved equity leads to improved quality.

Inclusive spaces are co-creative, so it makes entirely sense to co-design and co-create new proposals with the international or SAS or other doctors concerned. A diverse population is better served by a diverse workforce that has had similar experiences and understands their needs. Patients often identify closely with medical professionals with lived experiences, who can offer insight and sensitivity about how a recent diagnosis and ongoing impairment can affect patients. It is now pretty widely accepted that such experience is invaluable to the medical profession as a whole, and illustrates the importance of attracting and retaining learners.

In any curriculum, there would be ideally ‘constructive alignment‘ between learning outcomes, teaching and learning activities, and assessment outcomes. I don’t see why this cannot be extended to a legitimate expectation that all professionally registered psychiatrists who meet professional values and milestones in postgraduate education can apply for Fellowship. I think exams are one way of assessing the meeting of learning outcomes, but by far not only the means.

The de-emphasis on ‘time based curriculum’, more towards a competency based curriculum, is at odds with the idea that doctors mature ‘after ten years’ as a strange kind of magic. It surely would be preferable if the application for Fellowship could be assessed by a mentor and the College on the basis of objective criteria,, such as contribution to leadership, QI or research for example. The award of fellowship ought to be meaningful. The Royal College of Physicians, for example, my College, has done sterling work here. It could be that the MRCPsych is a ticket through the turnstile for this (skills based) raffle, or not. This is where research on the membership exams as a barrier to a career progression might be quite interesting. We already know there is an attrition in numbers between junior and senior psychiatrists, and maybe the real #choosepsychiatry battle is here for retention of the skilled workforce, recognised for their abilities regardless of background. Milou Silkens’ paper, which I came across from running journal club in Nottingham for our masters students in medical education, made an impact for me here.

Finally, I do get the ‘thing’ about voting rights. I think they are important, not least because of ‘P’ in the ‘PANEL’ principles of human rights. See for example the Scottish Human Rights Commission documentation. Some of us know, from rather bitter experience, that racism exists in the NHS. Some of us, more than others. The data are overwhelming and uncontroversial – and compelling. See Roger Kline‘s pieces on this.