Abstract
Over recent years it would appear that fewer junior doctors apply for training in psychiatry, while those who take up training are more likely to report demoralization and to cease such training. While many psychiatrists would be readily able to offer multiple reasons for dissatisfaction with a career in psychiatry, it appeared useful to obtain the view of informed observers of the psychiatric system – albeit with a distinct focus on the public psychiatric sector.
Method
To that end, as part of their Year 5 written examination for the University of New South Wales (UNSW) School of Psychiatry, 55 medical students were set the following open-ended question: “On the basis of your clinical experience, consider why doctors might be less likely to train in psychiatry these days than previously”, along with nine other questions in a 2 h examination. Answers were collated and qualitatively and quantitatively analysed.
All students had completed a 10 week term in psychiatry, and been allocated for much of their training to one of seven general hospital units, with most having some exposure to community psychiatric teams and some having limited exposure to private psychiatric practices.
Results
Several major themes were identified through in-depth qualitative analysis and are now detailed and discussed. The key areas are summarized as issues relating to lack of funding; training; treatment; perceived difficulty and stigma; patient related; personal; and other. All quoted material is excerpted from the students’ essays.
Lack of funding
Limited resources, leading to inability to provide optimal care (n = 29)
“The sense of battling upstream without a paddle is very strong in psychiatry. The burden of disease remains so high, funding is woefully deficient and treatment advances seem slow and small”.
The most prevailing theme to emerge relates to a strong sense of helplessness in the face of the chronic lack of resources in the public health system. Commonly used adjectives were “discouraging”, “demoralizing”, “disheartening”, “frustrating” and feeling “powerless”. The dominant observation was that psychiatrists are unable to perform a good job, or provide optimal treatment, as a result of limited funding that impacts on the availability of resources. As one student stated, there is a reluctance “to become involved in an area where you have to ‘fight’ for adequate and necessary resources” just to get the job done.
Shortage of beds (n = 13)
It was clear that most students were struck by the chronic bed shortage during their terms and thus viewed psychiatry as an area of medicine that is “overstretched”. This was highlighted by one student's expressed frustration at being forced to make “admission decisions with regard to the number of beds, not the needs of the patient”.
“A shortage of resources also means a shortage of beds. Due to this patients may need to be discharged slightly earlier than would be ideal. To find a job rewarding, you should be able to perform your duties to the best of your ability and to give the best possible care to your patients. So there is a discrepancy between the ideal way in which a psychiatrist could practise and the way in which they are forced to practise”.
Understaffed (n = 22)
Staff shortages resulting in increased work burden and long hours were also recorded as a significant feature negatively impacting on the students’ clinical experience.
Stress/pressure (n = 14)
Naturally, the strain of working in a chronically underfunded and inadequately staffed environment was perceived to generate high pressure and stress.
Inadequate training (n = 7)
Lack of funding was also implicated as having a detrimental effect on the quality of teaching received during training rotations. There was a strong sense of senior registrars being so busy that they “have little time or energy to invest in support or in nurturing a suitable environment for trainees”. One student also felt that “resident and intern psychiatry positions are more focused on blood results and general medical care, rather than their actual care”. This indicates that some students felt that the environment acted against optimal training, with trainees never adequately taught practical skills in how best to deal with psychiatric patients.
This issue is of concern to psychiatry as a teaching profession and raises an interesting issue as to whether more students would choose to pursue a career in psychiatry if they received more guidance, time and mentoring from their superiors during their student allocation. This may be an area that requires more consideration at a policy and pedagogical level.
Training issues
Exposure (n = 6)
The concept of exposure was a significant theme, referring to two different aspects of training. On the one hand, students commented that exposure to the field of psychiatry comes “very late in training” and that there was “no interest generated” throughout their medical degree. Others referred to exposure in the sense that what they see and experience during their practical training in the wards presents a very “bleak and traumatic” view of working in the field.
“Exposure as medical students is purely to ‘acute’ psychiatry (i.e. hospital-based crisis intervention), hence distorting the view of general psychiatric practice”.
Acute/crisis foci (n = 7)
To experience psychiatric treatment only within an acute setting was obviously overwhelming for many students. They commented on the “frustrating cycle” of relapse and continual presentation of patients. To experience care only at the crisis end of the spectrum gives a “distorted perspective” of working in psychiatry.
“Psychiatrists are under a considerable amount of stress due to a shortage of funding to mental health services. This shortage has created a situation where most of the attention needs to be paid towards the acute end of the spectrum. For a psychiatrist this means that they mainly deal with patients who are acutely unwell and often not very thankful for medical intervention. In addition, it is harder to achieve continuity of care due to long waiting lists. Again this means that the job is not rewarding, because you don't get to see the positives as much”.
In general, medical students’ exposure to the psychiatric field results in an image of the profession as stressful, traumatic and “personally frustrating”.
Treatment issues
Not “real medicine” (n = 20)
“[Psychiatry is] very different to the rest of medicine. As we are trained mainly to focus on medical illnesses, disease and physical symptoms, some find it hard to understand psychiatry”.
A distinctive issue impacting on students’ views about not entering a career in into psychiatry centred on the widespread perception that psychiatry is “not real medicine”. In general, it was perceived as “unscientific”, with “ambiguous” guidelines and treatment strategies. Many students found that the uncertainties surrounding diagnosis and treatment made it a “non-procedural profession”. For some, the fact that psychiatry is an area of medicine that is “not always black and white” was a matter of major concern. The typical perception is summed up by the following statement:
“Much of medicine is ‘evidence-based’ relying on clinical trials and precise diagnoses. Psychiatry may be considered an imprecise art, where basing practice on ‘evidence’ is more difficult than in other specialties. Diagnoses are often not clear (until the wisdom of retrospect can be applied) and we often treat based on symptoms, rather than based on a fixed underlying diagnosis”.
Symptomatology versus aetiology (n = 19)
In general, students described psychiatry as a field of medicine that is uncertain and at times even “very mysterious”, and their lack of confidence in the pathology of mental illness proved to be a significant concern. The focus on symptoms, rather than aetiology within psychiatric treatment, was regarded as inherently problematic.
“Many of the aetiological and neuropathological processes have still not been elicited. While treatments are helpful they are far from perfect. While offering massive potential for research developments, it also means that people who like a solid understanding of the process of disease and treatment are not likely to be attracted to the field of psychiatry”.
Increased risk of litigation (n = 8)
Anxiety over treatment and diagnostic uncertainty appeared due to beliefs that the exact causes of psychiatric illness and the precise mechanisms of treatment are “poorly understood”. This creates an underlying fear that an incorrect diagnosis could “potentially lead to situations open to legal prosecution”. Indeed, the risk of litigation and the extensive legal requirements related to the Mental Health Act and Mental Health Review Tribunal was an area of concern for many.
“Although the Mental Health Act and all it entails are designed to protect the clinician and patient, often it seems that much of the time spent in a day at the mental health unit is about notifying the proper authorities rather than spending time with the patient”.
Limitations of DSM classification system (n = 5)
Further, many students believe the DSM classification system is too restrictive, finding for example, that it lacks “intellectual engagement with the psychology of mental illness”. Others saw its limitations in providing “arbitrary criteria”. Clearly, the lack of clear-cut pathology and treatment guidelines is a source of anxiety that discourages some students from the field.
“There is little certainty about diagnosis, and treatment is fairly empirical… the lack of universal criteria often makes diagnosis difficult, leading to problems in allowing for definitive treatment”.
Reliance on pharmacology (n = 11)
Some students objected to the excessive reliance on psychotropic drugs in the treatment of psychiatric illness and to the fact that there was “no time to utilize psychotherapy”. The multi-disciplinary nature of psychiatric care means that various therapies are increasingly outsourced to other professions, particularly psychologists, leaving “no opportunity to engage on psychosocial elements”.
“Much of psychiatry is diagnosing and medication. The role of psychotherapy and comprehensive management plan, including support etc. is left for others to do, which makes the role of a psychiatrist appear less interesting”.
Students thus felt that psychiatrists working in the public health system are restricted to demonstrate expertise in only one element of care, which is administering medication. For some, that means the more interesting and challenging facets of psychiatric treatment (i.e. psychological therapy) were being undertaken by other professionals working in the mental health field.
No cures, no quick fix (n = 13)
“Many people prefer to be able to cure the patients as it serves to give more job satisfaction”.
In general, the view that there is “no cure” or quick fix for mental illness generated feelings of dissatisfaction. Students stated that it would be frustrating to put lots of effort and time into patient contact in ongoing care “with no guaranteed results”, making improvement “slow in comparison” to other domains of medicine. This culminates in a discouraging feeling that clinical efforts and treatment strategies are “unsuccessful”. For some, the problem of patient compliance, as well as the reality that effective treatment is also highly dependent on the efforts of the patient, was highlighted as an issue negatively impacting on the clinician's ability to provide optimal treatment outcomes and predict recovery. At the core is an issue of power and control.
“While most non-mental health illnesses can be cured or at least ameliorated with minimal patient compliance, mental health is an area where the patient and their family often bear the burden of the disease”.
No treatment advances (n = 5)
A related issue was the perception that there have been no advances in treatment in comparison with other medical specialties, which reflects the idea of psychiatry as an outdated and “unscientific” discipline. This belief is highlighted by the following comments.
“There is a lack of new medications in psychiatry that are developed based on known mechanisms of action. In this regard, psychiatry is not very advanced. Atypicals are slightly better than the typcicals, but not by much!”
In general, students expressed uneasiness about “conflicting evidence about the efficacy of some psychiatric treatments”. This situation predictably reinforces decisions not to specialize as a psychiatrist.
Perceived difficulty and stigma
Difficulty (n = 17)
“It makes one feel guilty if I have to compel treatment against the patient's wish. Moreover, why should one treat if the patient is not willing?”
These factors, compounded with chronic shortage of staff, beds and resources paint a dire picture of working in the mental health system that does not encourage interest in specialization. The long-term nature of the therapeutic relationships was also cited as problematic, particularly for students who value more efficient results and less direct patient contact.
“Rather than one discrete illness … psychiatrists have to be much more involved in the patient's life and that can be daunting for some. It is no longer about an illness treatment, but more about the general issues in a person's life”.
For such reasons, many students opted against a career in psychiatry, choosing a position more interesting even if not involving specialization. For example, some noted that they felt able to “practise psychiatry-related issues as a GP in less time” with no risk of “losing medical skills”.
Stigma (n = 20)
A significant number of students referred to “stigma” as a cause for disinterest in psychiatry. This theme is highly concerning and illustrates how entrenched stigmatizing attitudes towards the mentally ill are, even within the medical profession. The implication in this context was of “stigma by association”. Students have already experienced negative attitudes from practitioners in other fields of medicine towards those working in psychiatry. It appears that working with a stigmatized group such as the mentally ill made the profession “less glamorous”, something that clinicians may want to distance themselves from and “not want to be associated with”. As one respondent stated, “to say you're a psychiatrists is like saying ‘witchdoctor’”. There was also an underlying “fear that exposure to mental illness will cause mental illness in self”.
Patient-related issues
Aggressive patients/dangerous environment (n = 13)
The issues of personal safety, fear of aggressive and violent patients, and the “constant possibilities of harm, threats or harassment” working in the wards was a consistent response. The wards were seen as a dangerous environment in which the risks of violence and assault are high. It was not clear whether this view of psychiatry is based on difficulties personally experienced during rotations, or whether the negative perception relates to discriminating evaluations as a result of stigma.
Patients harder to treat (n = 9)
The belief that patients are more difficult to treat now, than in the past, was also highlighted. It appears that the fact that substance abuse is routinely involved in triggering psychotic episodes creates a moral dilemma for some students about which patients are worthy of treatment. This attitude is summed up by the following comment.
“The number of psychiatric admissions caused by substance abuse has sky-rocketed in the past decade or so. Psychiatrists may be off-put by the fact that these ‘self-inflicted’ psychiatric patients are taking over the hospitals and resources, while the patients with disorders such as schizophrenia and mania are being less well attended to”.
While the cycle of treatment and relapse caused by vulnerability to alcohol and illicit drug abuse is an understandable point of frustration, it also indicates a lack of understanding as to why some individuals engage in such destructive self-medicating behaviours and the positive affect a psychiatrist can have on ameliorating such problems. These views point to a significant gap in training.
Personal reasons
Lack of personal skills (n = 19)
Understandably, students also had personal reasons for not wishing to pursue a career in psychiatry. Some find the high level of patient contact required a turn-off. For example, some “preferred pathology to having to talk to patients” and disliked the level of interaction skills that are also necessary in an area of medicine that “requires teamwork and communication”.
Others stated that attributes of sensitivity and empathy may not come naturally and were “difficult to master”.
“Doctors are overrepresented with narcissistic traits and perfectionistic traits. Some with obsessive–compulsive traits as well. These are people very pre-occupied with their own thoughts, sense of entitlement and lack of empathy. Despite training to empathize with the patient, training in psychiatry requires real empathy, which many doctors lack”.
There was also a widespread view that working with mentally ill patients is simply too hard – either personally “demanding” or “emotionally draining”. There was an underlying fear that being in close proximity to mental illness would have negative personal consequences, with the belief, for example, that “spending time with patients who are depressed seems to suck the happiness out of you” or the “fear that one will go mad if that's all they do”.
Some acknowledged that the inability to help patients improve may be interpreted as a personal sign of failure. Others were simply uncomfortable working in an area of medicine where they felt they had “no power or control”. The need to retain power and control was central to many responses, but is most alarmingly summed up by one student.
“In the past, mental asylums were run with more physical and pharmacological restraints in place. This is not acceptable from a treatment or human rights point of view. However, it did give the physician a higher sense of power and control over his patients”.
This comment, while very confronting, is significant in drawing attention to the undercurrent of fear and stigma that exists for some students when contemplating working with psychiatric patients, and a countering need for control.
Low job satisfaction (n = 24)
The lack of job satisfaction, low appreciation and limited fulfilment was a consistent theme. In general, psychiatry was viewed as a field of medicine in which there is minimal gratitude, lack of respect and a lowered sense of personal reward. Students felt that you “do not get to feel the satisfaction of a ‘job well done’”. Being unable to deliver optimal treatment due to poor access to rehabilitation services and lack of funding, results in poor outcomes that are viewed as “professionally dissatisfying”. This view is highlighted by one student who comments that, in psychiatry:
“… disease processes are chronic and confronting. Dealing with people whose illness is causing debilitating social, occupational and forensic effects is challenging to one's self as a clinician. The perception that treatments often fail and little improvement is gained can make the thought of a life in psychiatric practice deficient in rewards”.
The fact that many patients “don't want help” was also a point of contention, as it negatively impacts on the clinician's sense of being appreciated and respected. Indeed, some students simply objected to working in a field of medicine in which patients have to be detained against their will. The fact that clinicians do not receive much gratitude from patients was also interpreted as a discouraging factor.
Low prestige/respect (n = 24)
There was a very strong sense that psychiatry is a specialty in which there is low prestige and little community and professional respect. In general, psychiatrists are perceived to be “looked down upon”, particularly among peers. The fact that the “community fails to distinguish between psychiatrist and psychologist” was also highlighted as problematic.
Income (n = 21)
Many students reasoned that the comparatively low remuneration psychiatrists received was a valid reason for reduced rates of recruitment. The issue of salary (reward system) could be linked to expectations relating to professional prestige.
Other
Paperwork/No lifestyle balance (n = 10)
Finally, the fact that there is a requirement to complete lots of paperwork (particularly in relation to legal matters) and to work hours ‘on-call’ meant that psychiatry is regarded as a medical specialty that does not afford a healthy lifestyle balance. The increased amount of “red tape” was also felt by some to impinge on their ability to give quality care to their patients.
Unsupportive working environment (n = 8)
Some students commented that psychiatrists do not receive much support from colleagues or other specialists, thus contributing to a sense of psychiatrists being very much on their own within the hospital system. Some indicated that “inappropriate referral”, particularly by sections of hospitals that attempt to “palm off” patients to psychiatry, was a source of frustration.
General
Other reasons cited for the reduction in recruitment were stereotyping of psychiatrists (although this comment was not explained further); requirements to work in rural areas; high rates of suicide among the profession; and low family support for the decision to become a psychiatrist.
Discussion
In general, the medical students’ attitude towards a career in psychiatry can be summarized in the words of one student:
Although the study of psychiatry has its rewards in better understanding of people and everyday interactions, the practice of psychiatry is an entirely different story, where there often seem to be more negatives than positives.
Issues relating to the limitations of treatment, lack of funding and the “unscientific” nature of psychiatry emerged as key themes. The relationship between low prestige, lack of (professional) respect and stigma is also apparent and points to a worrying trend that psychiatrists are negatively perceived within the broader hierarchy of the medical profession due to their association with mental illness and the “ambiguous” nature of treatment. Again, this highlights an alarming attitude and it is matter of concern that such a stigmatizing perspective is allowed to take root during the formative years of medical training.
The very negative evaluation of psychiatry as a career overviewed here needs to be balanced against the reality that the question was designed to elicit negative perceptions gained by students during their exposure to clinical psychiatry, and did not seek positive views. In many ways this question can be viewed as akin to a stage in any SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis, where the overall aim is to identify strengths, weaknesses, opportunities and threats, and that the current focus was only on the weaknesses. Our medical students who read this article can therefore predict next term's question.
In a previous study we surveyed the attitudes of medical students early in their medical courses at six differing Australian universities, and prior to their exposure to clinical psychiatry [1]. Their image of psychiatry was distinctly more positive, with students prejudging psychiatry as interesting and intellectually challenging, and providing a career that promised job satisfaction with good prospects and enjoyable work.
After discounting the bias of the question faced by students in the current study, it would appear likely that actual exposure of medical students to clinical psychiatry is a key factor in generating a set of negative judgments. If true, there are several major implications. In addition to those impacting on how to structure clinical psychiatry training, there is the wider issue – that the students’ judgements are in line with many other commentators (including psychiatrists, other mental health practitioners and consumers). These broader problems in the practise of psychiatry, particularly in the public sector, need to be addressed.
If psychiatry is to attract high-quality trainees and future psychiatrists, there is clearly a need to provide positive educational experiences for medical students that excite their imagination about a career or even a calling, rather than merely viewing it as an unsatisfactory job. Currently, medical students, like canaries in the mine, are sending a perturbing signal.