Abstract
There appears to be declining interest among medical students and junior doctors in training in psychiatry in western countries [1] that cannot be accounted for solely by the general reduction in interest in medicine as a profession [2]. Recruitment of trainee psychiatrists is dependent upon their attitudes towards both psychiatry and psychiatric patients, as well as its attractiveness as a specialty [3, 4]. Other factors such as personality [5, 6], clinical competence [7], cultural background [8, 9] and choice of medical school [10, 11] also influence attitudes, however, attitudes towards psychiatry and an intention to pursue a career in that specialty are not necessarily correlated [12]. Therefore, presenting a positive view of the specialty and encouraging medical students to consider a career in psychiatry are important components of clinical training [13].
Neilson [14] drew attention to the role of the psychiatry clerkship in influencing medical students to pursue a career in psychiatry, and subsequently several studies have shown that medical students' interest in psychiatry as a career increases during the psychiatry clerkship [15]. One group that followed medical students over a period of several years found that positive attitudes engendered during the psychiatry clerkship were maintained up till the end of final year of training – although reverting during the preregistration year [16–18]. They also found that, in addition to improving attitudes towards psychiatry, the psychiatry clerkship also increased the number of students planning a career in that specialty [16]. The transient nature of clerkship-related attitudinal change has been noted [19–21], with Creed and Goldberg [22] suggesting that any increase in positive attitudes towards psychiatry during and after a psychiatry clerkship merely offsets the decline in interest that occurs at other stages of clinical training. Furthermore, they found no correlation between students' attitudes towards psychiatry and their achievement in postclerkship examinations, whereas Sloan et al. [23] found that those students intending to specialize in psychiatry scored significantly better in their examinations.
It might be assumed that as medical students have had little exposure to psychiatry any lack of interest would reflect society's poor image of the discipline, while, for medical graduates, experience, training and role models might more positively contribute. In this paper we pursue the views of recently enrolled medical students regarding psychiatry as compared with a number of other career choices. We use an expanded questionnaire initially developed by North American researchers [24], who surveyed 223 freshman medical students from three South-western medical schools. The questionnaire seeks to rate potential career determinants (e.g. desire for interpersonal contact) and parameters defining career interest (e.g. lifestyle), while also obtaining qualitative data on the image of psychiatry held by the medical students.
We also compare responses of students considering a career in psychiatry with those expressing no interest, to inform us about psychiatry's comparative ‘image’ in Australia as a potential career choice.
Method
To obtain profession-naïve attitudes about career choices we gathered data from medical students early in their medical education, and administered the survey in the first two months of their commencing university. Six universities contributed, with two accepting only graduate medical student entry (Queensland and Sydney), three principally enrolling undergraduate medical students (New South Wales, Monash and Tasmania) and one (Newcastle) having both graduate and undergraduate entry. At each university, appropriate ethical permission was sought and students were approached in class and asked to complete the questionnaire anonymously.
We used a questionnaire developed for a North American study [24], with only minor modifications to reflect regional issues and obtain some additional details (e.g. sociodemographic, ethnicity and religious data). Background information on the student, any previous university degrees and details on alternative career choices considered by them was obtained. Students were requested to rank their principal determining interest in medicine, with three options (i.e. ‘research’; being involved in the ‘diagnosis and treatment of disease’; or ‘interpersonal interactions with patients’). They were asked to nominate the potential reasons for their choosing a career in one or more of six specific disciplines (i.e. medicine, surgery, psychiatry, paediatrics, obstetrics/gynaecology and general practice), nominate the reasons for and against being attracted to their choice, and to identify the importance of specific factors (e.g. lifestyle, prestige, ability, financial reward, the opportunity for interesting and challenging work, and the ability to help people) in dictating choice of career option.
Preserving the North American questionnaire strategy, students were requested to rate each listed career on a number of variables with five-point rating options assessing attractiveness. In addition, they were asked their high school exam result in English and whether they had been in a school debating team, and asked – in respect to their skills and talents – whether they were more interested in the sciences or the humanities. Finally, they were also given the opportunity to express open-ended views concerning their attitudes towards psychiatry.
Results
Across the six Australian medical schools, 655 students (53.4% female), with a mean age of 20.4 (SD 4.6) years, took part in the survey (see Table 1). The majority (60.2%) of respondents were born in Australia.
Career choice variables for whole sample and comparisons between students who would possibly choose a career in psychiatry and those not interesteda
When asked to assess the degree to which they, their family, their classmates and other physicians might separately respect the skills and knowledge of doctors in each nominated specialty, the students rated psychiatrists lowest in all four sets. The rank order of the students' mean ratings of their own comparative judgements about specialties were examined by analyses of variance with repeated measures, each specialty being compared with psychiatry. Results indicated that the students respected psychiatrists the least, returning a mean score of 2.0. Surgeons were respected most (1.32), followed by physicians (1.51), paediatricians (1.57), obstetricians and gynaecologists (1.74) and general practitioners (1.95). The only specialty returning significantly different ratings to psychiatry, however, was surgery (F = 181.8).
When asked to nominate each career as ‘chosen’ or as a ‘strong possibility’ on an ordinal scale, with the option of multiple nominations, psychiatry was the least likely career to be affirmed, receiving responses of 1.4% and 14.5%, respectively. Comparable data for other specialties were 12.6% and 48.9% for medicine, 10.6% and 36.9% for surgery, 2.8% and 17.8% for obstetrics/gynaecology, 9.5% and 38.3% for paediatrics and 5.1% and 35.6% for general practice.
Interested versus not interested in psychiatry
We then compared the 104 (15.9%) students who nominated psychiatry as either a ‘strong possibility’ or their ‘chosen career’ with the remaining 551 students who indicated no interest at all in psychiatry as a career choice. Gender was the only sociodemographic variable that distinguished students interested in psychiatry from those not (69.2% vs 50.5% female). Hence, all analyses of group comparisons by univariate analyses of variance for continuous measures and chisquared analyses for categorical variables were controlled for gender. Significant F values were reported at the P < 0.01 level after making a Bonferroni correction. Logistic regression analyses were conducted to identify predictors of students interested in a career in psychiatry, with reported statistics including: Wald (W), Odds Ratio (OR), and 95% Confidence Interval (CI). Secondary analyses examined for interactions between gender and interest in psychiatry, and further examinations of the significance of gender on aspects of career choice, were conducted by comparing responses of male and female students in separate analyses.
Table 1 reports comparisons across a variety of career choice variables. Those interested in psychiatry were more likely to have previously considered a career other than medicine, most distinctly psychology and the arts/humanities. They were less likely to have considered other health care-related careers such as dentistry, pharmacy and veterinary science, the biological sciences or careers in business. These differences in possible alternative careers possibly reflected their demonstrated greater interest in the humanities as compared to the sciences.
Predictably, students considering psychiatry as a possible career tended to be more likely to be interested in ‘interpersonal interaction with patients’ and were less likely to be interested in ‘diagnosis and treatment’. However, there were interactions with gender. Females were more likely than males to be interested in ‘interpersonal interaction with patients’, within both psychiatry (80.6% vs 58.1%, χ2 = 5.7, p < 0.05) and for alternative career choices (69.1% vs 52.6%, χ2 = 15.5, p < 0.001). In regard to the impact of ‘diagnosis and treatment’ issues, females were generally less interested than males, both in those considering psychiatry (25.0% vs 45.2%, χ2 = 4.1, p < 0.05) and alternative career choices (38.9% vs 54.9%, χ2 = 13.9, p < 0.001).
Perhaps not surprisingly, those considering psychiatry were less likely to consider surgery as a career and, on examining for interaction with gender, males were more likely than females to consider surgery as a career, whether considering psychiatry (48.4% vs 26.4%, χ2 = 4.7, p < 0.05) or not (60.9% vs 39.7%, χ2 = 24.6, p < 0.001). While there were no differences between groups on likelihood of choosing other career specialties, interactions with gender also extended to paediatrics as well as obstetrics and gynaecology. Females not considering psychiatry were more likely than males to consider paediatrics (56.5% vs 38.4%, χ2 = 18.1, p < 0.001) and obstetrics and gynaecology (29.2% vs 11.2%, χ2 = 27.1, p < 0.001) as possible career choices. There was a non-significant trend for a higher proportion of students interested in psychiatry to be born in Australia.
Of note, there was no significant difference between those interested or not in psychiatry in terms of their final high school English results and involvement in formal debating at school.
Comparisons were made between students considering psychiatry as a career and those not interested, on ratings of aspects of specialties (expanding medical frontier, contact with physician from that specialty and degree to which contact served as a good role model) and perception of respect for practitioners within those specialties from various perspectives (students and their family, classmates and other physicians). Lower ratings indicate greater weighting and items are reported significant at the P = 0.01 level. Students interested in psychiatry had a greater respect for psychiatrists than those not interested (1.69 vs 2.07, df = 1, 621, F = 8.4), but did not differ significantly in their perception of respect held by other physicians, classmates or family for psychiatrists. Conversely, students not interested in psychiatry had greater respect for paediatricians (1.55 vs 1.70, df = 1, 621, F = 7.2) and perceived other physicians to have greater respect for obstetricians/ gynaecologists (2.05 vs 2.26, df = 1, 613, F = 7.1). In regard to other aspects of the specialties, those interested in psychiatry were more likely to rate psychiatry as an expanding medical frontier (1.95 vs 2.58, df = 1, 610, F = 27.3) and to have had more contact with a psychiatrist (3.80 vs 4.15, df = 1, 615, F = 10.4).
Predictors (selected from Table 1) of a career interest in psychiatry were examined by logistic regression, identifying three significant variables – having previously considered a career as a psychologist (OR = 3.83, CI = 1.7–8.7); or being less interested in science (compared to the humanities) (OR = 0.37, CI = 0.2–0.6); and in being female (OR = 1.86, CI = 1.0–3.4).
Group comparisons of attractiveness ratings for the six medical specialties across a variety of career aspects, in which lower scores reflect increasing attractiveness, showed that students interested in psychiatry as a career rated the following specialty aspects as significantly more attractive (at 0.01 level) than those not interested: work enjoyment (2.04 vs 3.13, df = 1, 619, F = 87.3); interesting subject matter (1.31 vs 2.46, df = 1, 627, F = 85.7); job satisfaction (1.98 vs 2.89, df = 1, 627, F = 68.6); lifestyle (2.36 vs 3.12, df = 1, 624, F = 52.0); bright and interesting future (2.03 vs 2.81, df = 1, 617, F = 51.4); intellectual challenge (1.36 vs 2.05, df = 1, 625, F = 38.6); association with colleagues (2.22 vs 2.67, df = 1, 610, F = 15.2); degree to which it advances understanding/treatments (2.41 vs 2.80, df = 1, 615, F = 13.2); degree of help to patients (2.31 vs 2.67, df = 1, 618, F = 9.7); financial reward (2.26 vs 2.50, df = 1, 619, F = 7.0); and extent to which it draws upon training (2.85 vs 3.12, df = 1, 618, F = 6.6).
A logistic regression analysis of the 11 aspects of psychiatry rated significantly more attractive, identified four variables as significant predictors of interest in psychiatry: lifestyle (W = 12.5, p < 0.001, OR = 0.62, CI = 0.5–0.8); job satisfaction (W = 6.3, p < 0.12, OR = 0.68, CI = 0.5–0.9); interesting subject matter (W = 25.1, p < 0.001, OR = 0.38, CI = 0.3–0.6); and enjoyable work (W = 7.3, p < 0.007, OR = 0.67, CI = 0.5–0.9).
Qualitative data for those provisionally choosing psychiatry suggested a wish to help people with emotional problems, enjoying interactions with people, enjoying books on psychology and psychiatry and perceiving that psychiatry involved more reasonable work hours. Reasons for rejecting psychiatry were that it lacked satisfactory outcomes and was thus clinically frustrating, that it involved too many abstract concepts necessitating more thought than action, and that dealing with psychiatric patients was by its very nature ‘dangerous’. Furthermore, many students judged that psychiatry would be too stressful and may cause them to have psychological problems, and that they were not suited to the career in terms of their personality or past experiences.
Sex differences in rating career aspects
In separate supplementary analyses comparing male and female students, the females were more likely than males to express an interest in psychiatry as a career (20.7% vs 10.6%, χ2 = 12.2, p < 0.001), and likely to rate ‘interesting subject matter’ more highly than did males (2.16 vs 2.43, df = 637, t = − 2.9, p < 0.01). In choosing a career they were less interested than males in its prestige (3.06 vs 3.51, df = 645, t = 5.2, p < 0.01) and its financial reward (2.52 vs 2.94, df = 646, t = 5.5, p < 0.01) and less concerned by the degree to which psychiatry could help people (1.38 vs 1.22, df = 645, t = 3.1, p < 0.001). They ranked ‘interaction with patients’ as more important than males (71.5% vs 53.2%, χ2 = 23.1, p < 0.001) and ‘diagnosis and treatment’ as less important (36.0% vs 53.8%, χ2 = 20.7, p < 0.001). If they had not undertaken medicine, they were more likely to have considered health-care related fields, psychology and arts/humanities. They indicated a greater interest in humanities compared to science, with the reverse being true for males.
Discussion
The attitude of medical students towards psychiatry is of importance, being germane to the recruitment of prospective psychiatrists [25]. A question therefore arises: what characterizes students interested in pursuing a career in psychiatry, and at what point during their training are these intentions formed? If these characteristics and their influencing factors can be determined, then suitable strategies can be developed and incorporated into the teaching curricula of medical schools. This seemingly parochial objective can be argued as benefiting the whole profession, as psychiatry is interpersonally focused – involving understanding peoples' thoughts and problems, and helping them come to terms with the stigma and many losses associated with mental illness. It requires empathy, sophisticated communication skills and a genuine motivation to care. Such characteristics benefit all doctors and in particular general practitioners – (the largest specialty) and one that perhaps requires the greatest versatility. Thus, an interest in psychiatry is not as insular an objective to foster or to weight as it may first appear.
Our survey demonstrates that approximately one-sixth of current Australian first year medical students (15.9%) are open to the possibility of pursuing a career in psychiatry. This is clearly fertile ground and yet the eventual ‘yield’ is relatively poor [26, 27]. It is therefore important to identify and reinforce positive attributes of the specialty throughout undergraduate training and at the same time address student misconceptions.
In our survey, students who were interested or uninterested in psychiatry were similar in terms of age, size of community of origin, place of birth and religious background. The only sociodemographic and background variable that significantly distinguished our two groups was gender, with many more females entertaining a possible career in psychiatry – an observation that supports Shelley and Webb's [19] finding that women were more likely to entertain pursuit of a psychiatric career. In keeping with this, Alexander and Eagles study [28] examining gender-based attitudes towards psychiatry, found that females were more likely to have a more positive attitude and were more likely to improve in their clinical abilities during a psychiatry clerkship [29]. Our data assisted in identifying reasons for a greater interest in psychiatry by females. The greater interest among women towards psychiatry can be partly explained by the fact that their attraction to the specialty is interestdriven and so, when choosing a profession they are less interested in career aspects such as prestige and financial reward – in which psychiatry ranks poorly. Furthermore, it seems that women are perhaps less focused on outcome – as a proxy measure of competence/achievement or job satisfaction – and instead gain satisfaction and fulfilment from the process rather than the end goal. Hence their relative lack of interest in the degree to which patients can be helped (an aspect that is erroneously held to be poor) or in diagnosis and treatment and their ascription of greater importance to interaction with patients. These differences, along with their preference/ affinity for the humanities and health-care-related fields, including psychology, can perhaps be attributed to the stronger ‘nurturing’ instincts among women and their seemingly innate ability to communicate (girls mastering speech much earlier than boys) resulting in a more complete understanding of interpersonal issues. However, another important reason, not elicited by our survey, as to why women favour psychiatry, is that perhaps it is more permissive in achieving a balance between family life and the pursuit of specialization [5]. Since gender was a significant difference between our groups, and clearly an important influence, it was controlled for in all subsequent comparisons.
In tune with other studies that have found that students with a background in the humanities are more likely to take an interest in psychiatry [30], our results suggest that students interested in psychiatry had they not pursued medicine would have seriously considered careers in psychology, arts, humanities and social sciences.
In choosing a medical specialty, students interested or uninterested in psychiatry did not differ in rating the various aspects considered to be important in making such a choice. They ranked from most important to least important the ability to help people, an interest in the specialty, ability within the specialty, the lifestyle associated with it, the financial reward it offered and the prestige it bestowed. Those not interested in psychiatry were significantly more likely to choose surgery, underscoring perhaps the widely held perception that these two specialties are poles apart. As anticipated, those interested in psychiatry ranked interaction with patients higher. However, and somewhat surprisingly, this difference was not significant, whereas the greater affinity for diagnosis and treatment expressed by those not interested in psychiatry was significantly different to that shown by those interested in psychiatry. One reason may reflect a lack of awareness of psychiatry's growing biological focus. This is increasingly aligning it with other specialties and, furthermore, as psychologists and other mental health professionals compete with psychiatrists for providing psychotherapeutic treatments, psychiatry has progressively become less attractive [31], especially to those interested in patient interaction and psychotherapeutic means of treatment. Patient interaction and the lifestyle psychiatry offers are important influences in recruiting students into psychiatry [30], distinguishing, along with many other factors, those interested or not in psychiatry, in terms of their attractiveness ratings of aspects of psychiatry. It is of note, however, that the two aspects of psychiatry not rated as significantly more attractive by those interested in psychiatry were its prestige and scientific foundation. Overall, such data suggest that psychiatry has an image problem.
Prestige is a complex issue and one that has perhaps little impact, as it was ranked the least important aspect of any specialty in determining choice. However, psychiatry's scientific foundation is an important issue as it is possible that a perceived lack deters medical students from considering it as a career option. In some cultures, such is the bias within society that students fail to even acknowledge psychiatry as a medical specialty [8, 9]. Indeed, in one Arabian medical school almost 10% of medical students were unaware of the existence of psychiatric disorders [8]. Chandarana [32] suggested that students with limited knowledge of psychiatry are likely to rely more on the views of others than their own when considering career choice. We therefore asked students to rate their views of psychiatry and psychiatrists and the perceptions of classmates, family and other physicians. Predictably, those interested in psychiatry had greater respect for that specialty than those not interested, however, other physicians, classmates and family were not perceived to respect psychiatry differently. Noteworthy, is the fact that those interested in psychiatry had significantly more contact with psychiatrists and yet did not rate them as significantly better role models, whereas, those not interested in psychiatry, even in the absence of greater contact, rated obstetricians/gynaecologists and surgeons as significantly better role models. These findings are in keeping with Cutler's [33] observation that students who had seriously considered and then rejected a career in psychiatry were negatively influenced by the low status accorded psychiatry by physicians in other departments – a finding not unique to this study [34]. These observations raise important issues concerning the timing of exposure of medical students to psychiatric teaching and how psychiatry should be taught. Students have been found to develop more positive attitudes towards psychiatric patients as they progress and become more likely to appreciate psychiatric pathology as disabling and serious, however, they are also more likely to view psychiatric treatments as ineffective and psychiatry as less challenging [35].
Teaching behavioural sciences early in the curriculum as part of a comprehensive programme has been shown to be an effective way of influencing the attitudes of medical students towards psychiatry [36]. The timing of this intervention is particularly important, as any significant change in attitude is more likely to occur early in the curriculum prior to clinical placement [35]. However, direct contact with psychiatric patients is far more effective in producing attitudinal change than didactic teaching [37] and so clinical clerkships are important in consolidating the attitudes of those interested and perhaps dispelling the doubts of those that are less so. To this end it is essential that psychiatrists involved in teaching are motivated and that clinical teaching is presented in an interesting and engaging manner with emphasis on the diverse treatment options available and the fact that the majority of psychiatric cases have a good outcome. Clearly at present this is not being achieved, as many junior doctors do not feel confident managing psychiatric patients [38].
Some researchers have advocated that young doctors' perceptions of psychiatry be enhanced by psychiatrists providing additional training in the preregistration year [22], as it is important for all doctors to appreciate psychiatric illnesses and their management. In this context, the relationship of psychiatry with other specialties, and in particular general practice, is interesting as it also has relevance to the recruitment of psychiatric residents. Thompson [38], examining medical career choices in the UK, described a decline in the popularity of general practice and suggests that this is likely to decrease the number of entrants into psychiatry. However, in our study, interest in psychiatry did not correlate with a career interest in general practice or its perception. Furthermore, achievements in school such as the standard of English attainment and involvement in a debating team did not distinguish those interested in psychiatry. This suggests that medical students' interest in psychiatry and recruitment into the specialty is not currently differentially influenced by verbal skills, and is more likely to reflect other determinants.
Specialty preferences in the first year of medical school are somewhat predictive of future career choices [39]. To the extent that this is so, then the selection processes of medical schools need to be considered if an increase in recruitment into psychiatry is to be achieved [40]. However, if teaching and constructive clerkships can produce significant enduring attitudinal changes then these aspects of medical curricula also need to be reexamined. In practice, a combination of the two is probably required along with a focus on identifying those students interested in psychiatry and what it has to offer.
Our multivariate analysis, while restricted to only a limited set of predictor variables, contained in the database, provided an intuitively acceptable profile of those most interested in a career in psychiatry – being more interested in the humanities (than science), having previously considered a career in psychology and being female. The first two variables suggest that psychiatry is continuing to attract psychologically minded individuals, while females were differentially attracted to the interpersonal components. These factors perhaps need to be incorporated into recruitment strategies along with a greater focus on students that seek an interesting and intellectually challenging career providing ample patient interaction. This pattern of attitudes is clearly suited to many of the current roles within psychiatry. However, as stated earlier, the recent trend towards biological psychiatry has created a need for psychiatrists who are perhaps equally interested in diagnosis, treatment, science and research. In this respect, our study is useful as it profiles the strengths of psychiatry at the present and identifies aspects that need enhancing in the future. In essence, psychiatry and psychiatrists need to appeal to a much broader audience and this could be achieved, in part, by impressing upon students that psychiatry is an enjoyable career option, offering job satisfaction and good prospects. As psychiatrists, we are aware of the benefits and drawbacks of our profession, and have timely access to potential recruits. Hence we are suitably poised to carry forward such messages. The challenge we face, however, is to communicate our message to our ‘target’ audience in an effective and efficient manner so as to reduce the likelihood of future shrinkage of psychiatric recruitment.
Footnotes
Acknowledgements
We thank Dr Feifel, Chris Boyd, Kerrie Eyers and Emmy Giannolopoulos and Stan Catts for his help.