Abstract
The issue of low recruitment into psychiatry has been of growing concern in Australia and many other countries [1]. In the present paper we explore more deeply the reasons why students might actually consider a career in the field, because this might allow optimizing recruitment strategies. Results build on findings from our previous paper [2], which explored reasons why students might be unlikely to pursue a career in psychiatry following their clinical experience. Investigation found that diverse factors, such as lack of resources, reduced remuneration, low prestige and a stressful work environment, combine to produce a negative perception of psychiatry, which typically results in the field being viewed as an unappealing recruitment option. This negative conclusion is supported by findings from a British survey that psychiatry is viewed as the least desired clinical specialty in which to make a career [3]. To remedy this situation it is necessary to understand more deeply the influential factors that encourage students to be attracted to the field, as well as those that deter.
Method
As part of their Year 5 written examination in psychiatry at the University of New South Wales, 33 medical students were set the following question: ‘On the basis of your clinical experience, consider why a psychiatric career is an attractive choice these days’; one of 10 questions in a 2 h examination. All students had completed a 10 week term in psychiatry, with most of their training at Sydney teaching hospitals in the public system, and with some exposure to community psychiatry services. The 33 open-ended responses to the survey question were thematically analysed. Key themes were identified and are discussed.
Results
We list identified attractors in order of frequency of their nomination and provide some qualitative interpretation.
Interesting field (n = 29)
Almost all the students acknowledged that psychiatry is a dynamic, interesting and stimulating field that ‘engages the mind’ and brings together a wide variety of clinical skills: communication, liaison, research, analytical and diagnostic. For some students their psychiatric term exposed them to new issues and practices that were distinctly separate from other fields of medicine.
New concepts were encountered-from medico-legal to ethical which were completely different to the rest of medicine.
Working at the ‘boundaries between neuroscience and behaviour’ was of specific interest to some, while others appreciated that there is ‘never a dull moment in acute settings’. Clearly, psychiatry was not viewed as a boring field, as highlighted by the following comment.
The topic is interesting… if you enjoy talking and listening to people. Patients often have delusions or hallucinations which never get boring – always some new and unimaginable delusion that can appear. Psychiatry considers the person in a unique and interesting way…. The psychiatrist is freed to actually know a person and consider why it is that they are as they are.
Some students detailed the unique nature of working in this field of medicine and clearly grasped the magic and art of the profession.
Perhaps the most distinct feature of psychiatry which separates it from most other specialities is that no presentation is ever the same, since no two people are ever the same. This not only keeps clinical practice ‘fresh’ and variable, encouraging the clinician to view each patient as a whole new person, but can also present as a ‘challenge’ which stimulates the clinician to further his/her knowledge in the field.
Lifestyle (n = 26)
Lifestyle factors were cited consistently as reasons why psychiatry was viewed as an attractive choice by medical students. The value of the profession was perceived to lie in its flexibility, both in terms of working hours and practice settings, and even by the fact that the psychiatrists are ‘not locked in a room all day seeing patients, they are often moving around’. Students commented that there was a lot of ‘freedom to choose’ within the discipline, with little overtime demands and minimal emergency calls. In one case these lifestyle perks were questionably advocated, as illustrated in the following example.
You still have to be on call – but you don't need to rush in like an obstetrician and gynaecologist specialist – you can just give orders to sedate someone extremely agitated over the phone. Hence it can be a 9–5, 5 day a week job with the benefit of decent pay.
Satisfaction (n = 20)
The majority acknowledged that working in psychiatry is rewarding and that job satisfaction can be gained from helping alleviate people's psychological distress.
There is something very rewarding about being able to talk to patients and in doing so, be capable of eliciting a diagnosis and forming a plan of management. The diagnosis depends largely on the ability to understand the patient, rather than merely running a series of medical investigations, although of course, organic conditions need to be excluded. Additionally, it is more rewarding still to be able to provide the patient with some relief by teaching the coping mechanisms and non-pharmacological methods.
Some recognized that advances in treatment and funding have ensured better services and outcomes for patients, which encouraged them to feel more confident that they could ‘make a change’, as evidenced by the following comments.
I noticed that patients, once well, were extremely grateful for the help they received. Able to contribute by decreasing risk of harm by mentally ill patients and also to ‘save some lives’ directly by working with suicidal patients.
The fact that psychiatrists have the ability to ‘follow-up patients over time and be part of their progress’ was also viewed as unique to this field of medicine.
Patients are usually life-long sufferers and establishing that therapeutic relationship with so many diverse individuals is interesting and rewarding, as you can see their progress over years. Psychiatry allows for clinicians to develop a personal therapeutic relationship with each patient in a way which traditional medicine and surgical specialties lack.
Students also recognized that psychiatrists are in a privileged position to help destigmatize mental illness by helping raise:
…awareness of both the existence and severity of these conditions and help reduce the burden of disease on society.
Thus, being in a ‘position to advocate’ on behalf of vulnerable and marginalized groups within the community was regarded by some to be additionally satisfying. But it should be noted that although job satisfaction was rated positively, this element of reward may not specifically be related to working in a psychiatric setting with psychiatric patients, but may reflect the ethos of medical care in general.
Demand (n = 20)
A key factor in attracting students to the profession was the fact that there is ‘high demand’ for psychiatrists, ensuring that the discipline ‘will never become extinct’. The stability of job prospects, coupled with shortage of specialists, especially in rural areas, was seen as a positive, making it for some ‘both an exciting and lucrative opportunity’. Some students believed that psychiatric services were now ‘better funded’ after a rise in exposure in the ‘media/health spotlight’ and felt that this greater infrastructure support meant that there were more resources to help deal with the increased demand.
Variety (n = 19)
The attractiveness of a career in psychiatry also lay in its variety. Areas of subspecialization, from child, youth, family and old age were viewed as ensuring a variety of practice options. Additionally, students were drawn to the variation in practice settings, from hospital, outpatients, community settings, government and private practice. Training opportunities were also regarded as shorter and easier in comparison to other specialties, and thus appealed to those wishing to ‘fast-track’ their training.
It's easier to get into training programs as opposed to other popular specialties. I heard a rumour that you can get fast-tracked and become a registrar after 1 year of internship, due to shortage.
Research (n = 16)
Psychiatry was of interest to many due to its stimulating research opportunities, not necessarily for clinical practice. Because the discipline incorporates neuroscience, biology, genetics and psychology it was considered by some to be the ‘last frontier’, an ‘evolving area of medicine’ where researchers has the ‘opportunity to move the field forward’.
It's an exciting time to be joining the field – still much to be understood about mental illness and brain function and with more and more concrete evidence of brain dysfunction, it is an exciting time. With increased awareness comes increased funding, providing greater possibility of new research. With a paucity of specialists there is real opportunity to both research and travel under the banner of psychiatry.
Holistic (n = 14)
The multidisciplinary approach of psychiatric therapy appealed to those students who recognized that ‘health comprises physical, mental, and spiritual well-being’ and thus who appreciate a more holistic style of medicine, where they might deal with ‘people rather than disease’ and ‘play an active role in biopsychosocial management’. This continuity of care was important for a number of students, while others were drawn to the non-pharmacological methods and the opportunity to utilize psychotherapy skills.
It became exceedingly obvious very early on in the term that no other speciality entails the level of holistic care that psychiatry does. This is especially important for me. Specifically care given to the patient is always given within the context of the biopsychosocial framework. Psychiatrists don't only treat the patients’ medical illness, but also assist them with social functioning, accommodation and family dispute.
Financial (n = 15)
Fifteen students made specific reference to the financial rewards of practising psychiatry. In general it was regarded as ‘financially rewarding and secure as a profession’. Others acknowledged that the pay system was ‘adequate’ and ‘better than most GPs’.
Psychiatry is one of only a few professions where insurance premiums are not a real issue, allowing the clinician to care for his patients without having to worry about being left in financial ruin.
Personal (n = 12)
Many students acknowledged that they gained personally through their exposure to psychiatry, by enabling them to be ‘better able to relate’ to others, ‘see where people are coming from’ and ‘appreciate life from a different perspective’. In addition there was the following.
Biopsychosocial management strategies [can] be extrapolated into the way a clinician runs their own life and may help them be a more well adjusted person.
Undoubtedly the study of psychiatry has benefits for the clinician, but it is hoped that its benefits and utility are more deeply appreciated than the following self-focused needs.
Psychiatry may deliver powerful lessons about premorbid personalities – allowing me to avoid an unhappy marriage. In today's society, an understanding of people's behaviour, personality style is a wonderful benefit to an individual. Psychiatry examines this field more than any other and if nothing else, it'll save you from a bad marriage. It is also interesting. You get to hear some pretty wild stories, although the language sometimes used could shock an army sergeant. It also keeps you grounded and thankful for your own lucky life.
Perhaps of most interest is the following comment, which eloquently highlights how confronting and challenging the field is to medical students but how, with the right guidance and clinical experience, it can be shown to be inspiring, rewarding and compelling.
Moreover, psychiatry confronted my personal ethical boundaries. Thus far in medicine, rapport with the patient has been considered by me to be of paramount importance. However, in psychiatry, when the patient is at risk to themselves or others, rapport may need to be purposefully broken…. It was out duty of care to schedule her to go against her wishes – mush to the dislike of the patient. I have never experienced this before. Thus, psychiatry placed me outside my comfort zone – which is a wonderful experience, as it entails unequivocal personal growth, not just academic gain.
Patient contact (n = 9)
The high level of patient contact and interpersonal interaction was a positive feature for nine students.
One of the main appeals to me is the amount of patient contact, and the time to speak to each patient…which I really value because I feel as a doctor you can make a huge difference to the patient by taking the time to understand their needs and show that you care. One comes into contact with patients from all walks of life and can address many of their personal problems, giving hope to those who feel abandoned by society.
Team (n = 9)
Some students appreciated the team environment of the psychiatric setting and appreciated the model of working and liaising with other specialists, such as psychologists, social workers, occupational therapists, legal establishments and case managers. This may suggest that, if team work is perceived as crucial, psychiatry may be unappealing to those who prefer to work on their own, rely on their own judgement and retain ultimate responsibility for their treatment.
Some people enjoy the fact that there is very little ‘hands on’ diagnosis in psychiatry.
The fact that internships are conducted only within the public system means that students are not being exposed to other practice settings or patient populations, and may mean that they do not appreciate the independence that can be found in private practice.
This infers that, for some, the clinical experience during rotations does not showcase the depth and sophistication of psychiatric diagnosis and treatment.
Good student experience (n = 4)
It is worth noting that four students specifically mentioned their positive clinical experience, which evidently reflects well on the profession in general. They found the field to be ‘more personal’ than other areas of medicine.
Psychiatrists seem to be friendly, interested and concerned for the well-being of those around them (not just patients) without a lot of the narcissism found in many other specialties. I have noticed that many of the psychiatrists are the most empathetic of doctors I have ever met. To me this signifies the kind of profession psychiatry is – one where the patient is respected and valued more than most. For me, it seems obvious that this would in itself bring a lot of rewards.
It would appear that those students whose psychiatrists and registrars had time to nurture them and give feedback, positively reflected on their clinical experience, which highlights the benefits of good mentoring during the internship period.
My consultant was relaxed and always had time for a cuppa and to answer emails and the like as well as having plenty of time to be able to handle his workload. ‘Good undergraduate education experience – psychiatrist was keen and sharp. He answered lots of questions and reviewed my clinical case assignment thoughtfully, then gave evaluation including appraisal and criticism. This experience produced good impression about psychiatry.
Other: status
Some students also acknowledged that the status of psychiatry has improved, stating that there is ‘more respect from peers’, ‘improved appreciation’ and ‘increased reputation and standing of psychiatrists as ‘real’ medical practitioners’ and that psychiatrists are ‘finally considered to be ‘real’ doctors’. One student also made an intriguing point, that ‘psychiatrists are no longer viewed as agents from the Government’.
Discussion
The study design clearly risks biased findings: the students were effectively asked to find only the positives in a psychiatric career and may have judged that, to secure marks, certain positive responses would be favoured. Findings are therefore not representative of their overall judgment of psychiatry as a career but are weighted to attractors. Nevertheless we suspect that the students did not merely write to any expectations that a high mark would require some altruistic view because, in reality, self-interest was a dominant theme in their responses.
Thematic analysis of the 33 open-ended exam responses shows that the most appealing aspects of psychiatry were those related to lifestyle variables. The specialty was seen to afford flexibility and choice, with little overtime demands. These factors are valued by students seeking an appropriate work/life balance and support the Dorsey et al. findings that lifestyle factors are an increasingly important factor influencing career decisions [4].
It is interesting to note that some students remarked that they found the psychiatric wards a ‘lower stress environment’ that allowed clinicians to ‘work at a more reasonable pace’, in comparison to other medical specialties. This is in contrast to the findings of our previous paper, in which the majority of students regarded psychiatric patients as aggressive and difficult, and the environment as inherently stressful and dangerous [2].
Job satisfaction was referenced as the second most appealing factor in considering a career in psychiatry. Most students acknowledged that the field of mental health has greatly improved in the last decade and that psychiatrists are in a privileged position to make a difference, both to the individual patient and to the broader issue of destigmatization. In discussing this topic it is of interest that only one student mentioned ‘empathy with the patient group’ as a rewarding element of psychiatry, given that a previous survey of consultant psychiatrists cited empathy as the most important factor in their work [5]. In a survey of more junior Australian medical students’ interest in psychiatry, it was reported that the ability to help patients was the most highly rated factor determining choice [1].
Students recognized that increased community awareness of mental health problems meant that more people would seek professional help. This was understood to increase demand for services and provide clinicians with exciting and lucrative opportunities. But the view that services are better funded is contrary to our previous findings, in which limited resources, shortage of beds and understaffing were regarded as the most frustrating aspects impeding clinicians’ ability to provide optimum care [2].
While some students stated that improved status was a positive factor encouraging them into the field, previous analysis cited the low level of prestige as a key factor in dissuading students from specialization. The fact that the theme is raised again in this context could indicate that the issue of peer respect and professional standing is still of underlying concern.
Of concern is the fact that only four students nominated good experiences as a student as an influential factor in considering a career in psychiatry. The importance of quality learning environment in the early stages of medical training has been detailed in the literature. Findings of an earlier survey were that approximately one-sixth of Australian first year medical students were open to the possibility of a psychiatric career [1]. Yet, as the authors point out, despite this ‘fertile ground’, the ‘yield’ is relatively poor. Similarly, El-Sayeh et al. relate the crisis in UK psychiatry to negative undergraduate experiences, suggesting that improvements must be made to the formal teaching environment over the limitations of the current apprenticeship model [6].
This reality reinforces the necessity for providing a positive experience during the clinical term. The value of inspiring clinical experience is reflected by Dein et al. who showed, in a survey of 72 consultants, that 9.4% cited the medical school teaching of the subject as one of the most important reasons for choosing psychiatry as a career, highlighting ‘the lasting influence of medical school exposure to psychiatry’ [5]. The importance of the education environment is further supported by McParland et al. [7]. Their study showed that students’ intentions to pursue a career in psychiatry were significantly affected by experiences during the clinical term. The importance of mentorship and practical, valuable hands-on learning experiences is thus underscored, indicating that students’ attitudes and perceptions can be influenced and encouraged by the quality of experiences during attachment. As El-Sayeh et al. pointed out, awareness of the fascinating aspects of psychiatry is more likely to be generated by a ‘charismatic tutor or interesting patient’, indicating that effective recruitment is likely to be predicated on the actions of clinical teachers [6]. The benefits of mentoring are corroborated by some students’ comments in the present analysis.
Conclusion
The perceived positives of specialization in psychiatry can be summarized with the words of one student.
Psychiatry is a fascinating science giving one the privilege of talking to people about the most intimate details of their life and empowering them with therapeutic options, while also allowing the psychiatrist to pursue other interests.
In general, it would appear that for most of the medical students, psychiatry was perceived as an adequate career option with the main benefits found in the lifestyle it affords, outside of work. It is evident that psychiatry did not stand out as a calling for any of the students surveyed. Indeed, there was a distinct lack of responses that evidenced any real passion or ‘fire in the blood’ for pursuing a psychiatric career. These findings clearly indicate that it is time for action: the psychiatric profession needs to re-think its approach to the teaching and learning environment during the trainee period if improvements to recruitment are to be made.
Footnotes
Acknowledgements
This study was supported by funding from an NHMRC Program Grant (510135), the NSW Department of Health and the Black Dog Institute. Assistance from the School of Psychiatry, UNSW, is also gratefully acknowledged.