“I too had certain prejudices about psychiatry”, confess Franck, 29, intern in psychiatry in a public hospital in Ile-de-France. Before switching, at the start of his internship, from general medicine to this discipline, he had “fear of having done six years of medicine to end up no longer auscultating”. Except that the “psy is a doctor like the others” who “also saves lives”he wishes to recall.
Franck is not the only one to have had a truncated vision of psychiatry. According to a national survey carried out by the French Federative Association of Psychiatric Students (Affep) in 2015, 56% of medical students think that a psychiatric intern probably has “personal psychiatric history” where he is “weird”. A bad reputation which contributes to the lack of psychiatrists, for lack of trained students in sufficient numbers.
If France displays, with around 15,000 psychiatrists (45% of whom practice as a liberal) listed in 2013, one of the highest densities of these specialists in Europe with 22 professionals per 100,000 inhabitants, there are strong disparities between departments, as raised by the Senate report on mental health and the future of psychiatry ( 2013). Concerning liberal and mixed psychiatrists, the ratio is 21 professionals per 100,000 inhabitants in Gironde compared to 2 per 100,000 in Vendée in 2009. As for salaried psychiatrists, when there are 27 doctors per 100,000 inhabitants in Paris, they are not than 5 per 100,000 in Indre-et-Loire.
A disparate situation that subjects the profession to “high tension” and which highlights a shortage “serious and serious” of hospital psychiatrists facing a “growing demand for care since the Covid-19 pandemic”underlines Isabelle Secret-Bobolakis, general secretary of the French Federation of Psychiatry (FFP) and head of the adult psychiatry department at the Marne-la-Vallée hospital center (Seine-et-Marne).
“About 30% of hospital practitioner positions are currently unfilled. There are many places, remote, far from major cities, where there is a psychiatric desert.”
Isabelle Secret-Bobolakis, psychiatristat franceinfo
Recruitment difficulties in public hospitals are particularly felt in the Paris region where, on “15 departures of psychiatrists practicing in hospitals, only five are replaced, including three in interim”, says the Secretary General. Staff shortages, Jean-Del, intern in the last year of psychiatry in Ile-de-France, has also noted them since the beginning of his internship. During most of his seven internships, “lack of staff”. “In the public sector hospital where I was during my second internship, they had to close 20 beds, the doctors were leaving, there were no more paramedics”he recalls.
This lack of arms has its origins in the crisis that the public hospital has been going through for several years, but also in a continuing crisis of vocations. Between 2012 and 2018, “between 1% and 4%” positions for interns in psychiatry remained vacant at the end of the selection procedure after the national ranking examination (ECN), which determines in which specialty the students will do their internship. But in 2019, this percentage increased to “17.5%” note Marine Lardinois, psychiatrist and vice-president of the Association of young psychiatrists and young addictologists (Ajpja). Psychiatry stagnates in 40th place, out of 44, of the specialties chosen according to statistics on the ECNs of 2020.
Why such a lack of love for psychiatry on the part of students? His side “less spectacular than surgery” the dessert, esteem Isabelle Secret-Bobolakis. But also his bad reputation. “In the medical community, we are placed quite low on the scale of consideration, with occupational physicians, public health and biologistsnotes Frank. For many students, a psychiatrist is not really a doctor. We don’t know how to heal, in the eyes of others.”
This speaker in medical school admits that very often, when he talks about his specialty with externs, “crazy” and “madness” are the first words that come out of their mouths. “Very quickly they claim that the psychiatrist is a person as crazy as his patients”, reveals the inside. “We suffer from the idea that other medical students have of our patients, and therefore of us”, completes Jean-Del.
“Not all patients are like Kevin in the movie ‘Split’ with 23 different personalities or like the inmates of ‘One Flew Over the Cuckoo’s Nest’.”
Jean-Del, intern in psychiatryat franceinfo
This vision, Jean-Del also had to deconstruct it within his own family. “At home, everyone works in the medical field, but no one understood my choice when I said I was going to psychiatryhe recalls. I had to remove all the misconceptions they had about this specialty.” Possible consequence of “experience of very significant stigma” of their specialty“40% of practicing psychiatrists often or always avoid mentioning their specialty to the people they meet”notes Marine Lardinois, according to statistics from the #ChoisirPsychiatrie survey, launched in May 2021, which must be published before September 2022. As part of this survey, conducted by three associations of students and young doctors in psychiatry*, nearly 3,400 people (externs in medicine, interns in psychiatry and qualified psychiatrists) were interviewed in order to understand the determinants of attractiveness of psychiatry.
Beyond the negative image from which psychiatry suffers, these three associations wanted to know why, in recent years, fewer and fewer future interns have requested this specialization. It shows that in addition to the biased representation that students have of psychiatry, the courses and internships preceding the internship have consequences on the choice of this specialization. If, during the externship, certain internships are compulsory, such as emergencies, general medicine or surgery, psychiatry often remains shunned. “Two out of five students do not do any internship in psychiatrynotes Nicolas Lunel, outgoing president of the National Association of Medical Students of France (Anemf). That’s a lot of students who don’t go through it, even until the end of their course, and few faculties of medicine present all the possible specialties.”
“It’s hard to get a good idea if you never go into psychiatry during your medical school years.”
Jean-Del, intern in psychiatryat franceinfo
However, 70% of students who have done an internship in psychiatry report that “the meeting with the patients as well as the discussions with the teams positively modified their perception of this speciality”, emphasizes Nicolas Lunel.
Respondents raised another pitfall: the theoretical training which, with its lectures, remains poorly suited to the teaching of psychiatry during the last three years of common core studies, in externship. “The intervention, in the courses, of expert patients, who have experiential knowledge on the disorders, the experience of the care and the recovery process, would allow a real change in the apprehension of this specialty. This would make real and concrete for students the fact that a person who suffers from psychic disorders can recover”, insists Marine Lardinois.
Pending the submission of a report to the ministerial delegate for mental health and psychiatry to the Minister of Solidarity and Health, Professor Frank Bellivier, the three associations are refining their recommendations to improve the attractiveness of psychiatry. Like the possibility of setting up a compulsory internship for externs, of developing practical lessons, of better promoting careers or even of offering more opportunities to do research. These recommendations are in line with the missions of the government’s mental health and psychiatry roadmap, which aims, in particular, to improve the attractiveness of the profession.
Yes, “today, not all retirees are replaced”according to the secretary general of the French Federation of Psychiatry, the young generation nevertheless says “confident”. “These next ten years will be years of restructuring, there are more and more initiatives in the field to motivate students to come to psychiatry and the reservoir of interns, who will be the psychiatrists of tomorrow, is motivated”, assures Ilia Humbert, the president of the French Federative Association of Psychiatry Students (Affep). A vision shared by Franck, who feels “that with the health crisis, the issue of mental health has regained a form of interest among young doctors”.
Jean-Del and Franck continue to do educational work with their peers and the externs they meet in order to restore the image of psychiatry. “Our generation is more inclined to build bridges between the different specialtiesassures Frank. And psychiatry is the richest and most transversal.”
* The National Association of Medical Students of France (Anemf), the French Federative Association of Psychiatric Students (Affep) and the Association of Young Psychiatrists and Young Addictologists (Ajpja).