Advanced Search

INTERNATIONALEDUCATIONREPORT | May 01, 2009

The Effect of Clinical Clerkship on Students’ Attitudes Toward Psychiatry in Karachi, Pakistan

Ayesha Sajid; Murad M. Khan; Murtaza Shakir; Riffat Moazam-Zaman; Asad Ali

Academic Psychiatry 2009;33:212-214.

View Article Information

Received August 8, 2007; revised November 12 and December 19, 2007, and January 16, 2008; accepted January 28, 2008. Drs. Sajid, Khan, Shakir, and Moazam-Zaman are affiliated with the Department of Psychiatry, Aga Khan University; Dr. Asad is affiliated with Shifa Hospital, Karachi. Address correspondence to Dr. Murad M Khan, Department of Psychiatry, Aga Khan University, Stadium Rd., PO Box 3500, Karachi 74800, PAKISTAN; murad.khan@aku.edu (e-mail).

Article

Tables

References

text A A A

Abstract

Objective: Attitudes of medical students toward a specialty is strongly related to their future choice of specialty. In developing countries like Pakistan, where there is a shortage of psychiatrists, there is a need to assess the effect of exposure to psychiatry on medical students. Methods: The authors conducted a survey of fourth-year medical students at Aga Khan University in Karachi, Pakistan. Results: Psychiatry clerkship had an overall positive attitude toward psychiatric illness, patients, and psychiatrists, but no effect on students’ choice of psychiatry as a career. Conclusion: Psychiatry teaching needs to be made more relevant to the rest of the medical curricula. This may improve students’ interest and their future choice of psychiatry as an area of specialization.

Figures in this Article

Pakistan is a South Asian developing Islamic country with a population of 162 million. The country’s health expenditure is less than 1% of the annual Gross Domestic Product (GDP) and is focused on communicable diseases, particularly maternal and child health. This is despite high prevalence rates for common mental disorders of approximately 30% (¹). There are fewer than 300 properly trained psychiatrists in the country, with a ratio of one psychiatrist to 500,000 people.

Psychiatry is a neglected subject in most medical schools in Pakistan and students have little or no exposure to mental health issues during undergraduate training. The Pakistan Medical and Dental Council, the body that regulates medical teaching in Pakistan, requires the theoretical teaching of psychiatry, but not a separate certifying examination. Students, therefore, do not take the subject seriously, leading to low interest and low recruitment to the specialty (²). Several studies have shown that students’ experience a positive change in attitude following their undergraduate exposure to psychiatry (³, ⁴).

To our knowledge medical students’ attitudes toward psychiatry before and after exposure to psychiatry clerkship has not been previously studied in Pakistan. The aim of our study, therefore, was to determine the change in medical students’ attitudes toward psychiatry following their clerkship.

Methods

Unlike other medical schools in Pakistan, students at the Aga Khan University (7—10 at a time) undergo a structured 4-week clinical clerkship in psychiatry in the fourth year. The clerkship is full-time and consists of teaching in both inpatient and outpatient settings. This is complemented by case presentations, small group discussions, a journal club, and a research project. A behavioral sciences program runs vertically throughout the 5 years of medical school training. At the end of the clerkship students are examined through written and oral exams. At the end of the year, students have to pass a certifying examination in psychiatry.

Fourth-year medical students from the class of 2005 (second year of clinical rotations) were asked to anonymously participate in the study, which was not related to their clerkship. Participation was voluntary and refusal would not affect student grades in any way.

We developed a questionnaire after reviewing the literature and after detailed discussions with consultants in the psychiatry department. It was based on a number of similar questionnaires developed for the same purpose (³—⁵). The 21 items of the questionnaire explored psychiatry both as a subject and a career option, attitudes toward psychiatric patients, and attitudes toward psychiatric illness (full version of questionnaire available upon request). The ethics committee of the department of psychiatry approved the study.

Results

This self-administered questionnaire was distributed to the class of 89 students, out of which 67 responded before the clerkship (75%) and 47 responded at the end of the clerkship (53%). The preclerkship sample included 54% men, while the postclerkship included 64% men. The mean age of the students was 22 years old.

The number of students who considered psychiatric skills essential for all medical practitioners increased significantly from 60% to 100% after the clerkship (Table 1). However, at the end of their rotation, psychiatry was perceived as a depressing subject to study by more students. The percentage of students who disagreed with the idea that the practice of psychiatry was unrewarding decreased from 70% to 51% after the clerkship. The clerkship however, had no impact on the students’ choice to pursue psychiatry as a career. Before the clerkship, 84% of students felt that psychiatrists can help their patients, but that value dropped to 68% after the clerkship (Table 1).

After the clerkship, more students who initially had no opinion regarding aggression by psychiatric patients considered patients not to be aggressive, and psychiatric patients were perceived as being more interesting than healthy people. Students thought that psychiatric patients were just as human as any other individual irrespective of the clerkship (Table 1).

There was increased willingness among the students to consult a psychiatrist if they needed psychiatric help. Postclerkship, the number of students who thought they had sometimes experienced feelings and thoughts that were similar to those of a psychiatric patient increased from 49% to 72%. A majority of the students (99%) believed that psychiatric illness deserved as much attention as physical illness and the opinion did not significantly change after the rotation. More students considered psychiatric skills essential for all medical practitioners (Table 1).

Discussion

Our findings show that the psychiatric clerkship had an overall positive effect on the attitudes of medical students toward psychiatry, psychiatrists, and mental illness. Although this study did not focus on different aspects of psychiatry either as a subject or a career, we found a decrease in the number of students perceiving psychiatry as not relevant to medicine (from 94% to 77%), with more students remaining indecisive after the clerkship. On the other hand, students perceiving psychiatry to be an important part of the medical curriculum increased from 87% to 91% (Table 1). This conflicting data could be a result of fewer number of postclerkship respondents.

About one-quarter of the students expressed a wish to specialize in psychiatry. This is a relatively high number and may be related to the fact that students had yet to be exposed to specialties like internal medicine and surgery in their final year. The clerkship had no role, positive or negative, on psychiatry as career choice. Students’ attitudes toward psychiatry as a subject may have been independent of their feelings regarding psychiatry as a career choice.

A number of studies have demonstrated that along with clinical clerkship, attitudes are shaped by diverse factors such as the medical school (⁶), clinical competence (⁷), and cultural background (⁸). In our study we found that even before the clerkship, students appeared to have a positive attitude toward different aspects of the specialty (e.g., toward psychiatric patients) as well as psychiatry as a career choice. Maybe this was due to a behavioral sciences course taught at this medical school during preclinical years.

Zimny et al. (⁹) reviewed several possible factors and found that mental health work and experience with a psychiatric patient were premedical school factors that led to positive views of psychiatry. Midclerkship factors that affected the decision to have a career in psychiatry included clinical psychiatric electives, the psychiatrist-patient relationship, inpatient experiences during clerkship, and control over practice hours (⁸—⁹). Exposure to behavioral science topics early in medical school program and enriching course content has also been shown to increase the likelihood that psychiatry would be chosen as a career (¹⁰).

The study has several limitations. This was a single-center study with small number of participants. Our findings cannot be generalized to other medical schools in Pakistan. Preclerkship responses may have been influenced by behavioral sciences teaching in the first 2 years of medical studies. Also, there were fewer respondents after the clerkship, which may have affected the results.

Further work is needed to study attitudes before and during undergraduate training. Similar studies need to be carried out in other medical schools in Pakistan. This may help clerkships increase the number of students considering psychiatry as a career choice.

View Large | Download Slide(.ppt)
Add to My POL

TABLE 1. Summary of Pre- and Postclerkship Questionnaire Responses

Acknowledgments

At the time of submission, the authors declared no competing interests.

References

Mirza I, Jenkins R: Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. Br Med J 2004; 328:794—797

Naeem F, Ayub M: Psychiatric training in Pakistan. Med Edu Online [serial online] 2004; 9:19

Burra P, Kalin R, Leichner P: The ATP 30: a scale measuring medical students’ attitudes to psychiatry. Med Edu 1982; 16:31—38

Wilkinson DG, Greer S, Toone BK: Medical students’ attitudes to psychiatry. Psychol Med 1983; 13:185—192

Nielsen AC, Eaton JS: Medical students’ attitudes about psychiatry: implications for psychiatric recruitment. Arch Gen Psychiatry 1981; 38:1144—1154

Weissman SH, Haynes RA, Killian CD, et al: A model to determine the influence of medical school on students’ career choice: psychiatry, case study. Academic Med 1994; 69:58—59

Kelly B, Raphael B, Byrne G: The evaluation of teaching in undergraduate psychiatric education: students’ attitudes to psychiatry and the evaluation of clinical competency. Med Teacher 1991; 13:77—87

Soufi HE, Raoof AMS: Attitude of medical students toward psychiatry. Med Edu 1992; 26:38—41

Zimny GH, Sata LS: Influence on factors before and during medical school on choice of psychiatry as a specialty. Am J Psychiatry 1986; 143:77—80

Malhi GS, Parker K, Carr VJ, et al: Attitudes toward psychiatry among students entering medical school. Acta Psych Scan 2003; 107:424—429