Like most countries, Germany has an ongoing shortage of Child and Adolescent Psychiatrists (CAPs). In recent years, CAPs have been among the most sought-after professionals of all medical specialists in Germany (1). In a European survey about training conditions in Child and Adolescent Psychiatry (CAP), the most often mentioned major difficulties in CAP daily practice were long waiting lists for patients and the lack of CAP professionals (2). In the United States, the shortage problem in CAP is similar, and especially affects patients from rural areas or those living in poverty (3). A study on the reasons for the shortage of CAPs identified inadequate support for CAP in academic institutions, limited graduate medical education funding, lower clinical revenues under a managed-care environment and a devalued image of the profession as important factors (4). Even though there are country-specific features in CAP training, studies from different countries show similar problems (4–6). Medical students in Germany attend medical school for six years, with the last year consisting of a clinical rotation through internal medicine, surgery, and a subspecialty of choice. The CAP teaching in medical school usually occurs in Year 4 or 5 as part of the psychiatry or pediatrics curriculum and comprises a mix of lectures and of bedside teaching. Postgraduate CAP training covers four years of CAP and one year of adult psychiatry or pediatrics (7).

There are only few studies focusing on students’ attitudes toward CAP. In Martin et al.’s study (8) of medical students’ perceptions of CAP, the most frequently reported positive aspect was the opportunity to help children and the most frequently perceived negative aspect was that CAP seems emotionally stressful. Shaw et al. (9) compared psychiatry and CAP residents and found CAP residents to be more empathic, socially related, and interested in quality of life. In an older survey, Weissmann and Bashook (10) detected almost no difference between characteristics of prospective CAPs and general psychiatrists.

For general psychiatry, there is more literature on the attitude of medical students toward psychiatry as a possible career choice (for a review, see reference 11). Students rate the field's intellectual content and quality of life higher, and had frequently had experiences with mentally ill family members (12–15). Perceived negatives are low status, low earning potential, challenges of treating chronic patients who do not necessarily get better, general discomfort with psychiatric patients, and the fact that relatives of medical students tend to regard psychiatry as a poor utilization of medical training (16–18).

Improving recruitment strategies toward medical students is one of the most obvious strategy to improve the described shortage of CAPs. One approach to recruitment could be to focus on students who are most likely to choose this subspecialty and use approaches based on scientific data (19). Therefore, we investigated medical students’ attitudes toward CAP as a medical subject as well as a possible career choice and the characteristics of those medical students showing increased interest in CAP. We aimed to address four questions: What is the interest in and view of the relevance of CAP? How many students could envisage CAP as a possible career choice at the point of time of their first CAP lecture? What are the reasons for and against this decision? What are specific characteristics of students who consider CAP as a possible career choice?

Participants

The study was distributed to 1,029 medical students attending CAP lectures at 10 public medical schools at German universities (Marburg, Frankfurt, Hamburg, Munich, Freiburg, Ulm, Rostock, Goettingen, Wuerzburg, and Aachen). Schools were chosen by geographical criteria (balance between different regions of Germany) and whether CAP lecture series lasted one semester (6 months). Information on the total number of enrolled medical students of the surveyed year was collected from the dean’s office of each medical school in order to determine the potential subject population. A minimum participation rate of > 20% was requested to reduce the selection bias. Data from three medical schools were eliminated from analysis. In one medical school, the participants were mostly first-year students (without experience with clinical courses); in two others, the minimum participation rate was not reached.

Questionnaire

The authors developed a self-report questionnaire based on the existing literature (8, 20; available from the corresponding author). This instrument consisted of five main items on attitudes toward CAP, including reasons for and against CAP as a possible career choice, and nine additional items addressing socio-demographic data and prior experiences with general psychiatry or CAP. Apart from the items “General interest in CAP” and “Relevance of basic CAP knowledge”, which were answered on a 5-point Likert scale, items were answered dichotomously (“agree”/ “disagree”).

Procedures

The questionnaires were distributed during the first lecture of CAP lecture series (October 2007 – April 2008) and were completed anonymously. This time was chosen to reduce a possible attendance bias, as in Germany the first lecture in a subspecialty is usually attended by the majority of students because information about requirements is given in this lecture. In accordance with German legal regulations, an institutional approval was not required for this study.

Data Analysis

Data were analyzed with PASW Statistics 18.0 (2010, Chicago, USA). For the analysis of respondents’ characteristics, general interest, appraisal of relevance, and the number of students envisaging CAP as a possible career choice, we used descriptive statistics. To identify the career choice predictors, a logistic-regression analysis was performed. Participants’ consideration of CAP as a career choice was the independent measure and socio-demographic data, former experience with general psychiatry and CAP and attitudes toward CAP were entered as predictors.

Description of the Sample

The mean return rate (returned per distributed questionnaires) was 94% (range: 81%–100%). We included data from 574 fourth- or fifth-year medical students from seven medical schools. The mean age of the students was 24.5 years standard deviation [SD]: 2.6; range: 21–48], and 66.4% (381/574) were female (Table 1).

General Interest in CAP

The students were asked to judge their general interest in CAP in comparison with other medical subspecialties on a 5-point Likert scale (1: very high interest to 5: no interest). The mean score was 2.66 (SD: 0.82). A proportion of 42.9% rated their interest for CAP as “very high” or “high” (Table 2, first column). Additionally, the participants were asked to estimate the relevance of basic CAP knowledge for their prospective work as a physician (regardless of the prospective medical subspecialty) on a similar Likert scale ranging from 1 (very high relevance) to 5 (no relevance). The mean score was 2.35 (SD: 0.76). In summary, 59.4% of the medical students judged the relevance of CAP basic knowledge as “high” or “very high” (Table 2, second column).

CAP as a Possible Career Choice

Students were further asked if they could envisage CAP specialty training as a possible career choice after graduating from medical school. One-quarter of the students answered with “yes” (25.4%; N=146). In order to understand what influenced this decision, we asked this subgroup to choose three out of nine positive reasons. Almost two-thirds of the medical students who consider CAP as a possible career choice assessed the phenomenology of CAP disorders (“interesting clinical cases”) as a reason for CAP as a possible future path (65.8%; N=96; Figure 1). Other positives of CAP from the participants’ point of view are shown in Figure 1. About three-quarters answered the career question with “no” (74.6%; N=428). We then asked these students to choose three out of eight negative reasons for their decision. The majority (54.8%; N=235) had already chosen another medical subspecialty when attending their first CAP lecture. The frequencies of other reasons against CAP as a possible career choice are pictured in Figure 2.

Medical Students Considering CAP as a Possible Career Choice

In order to identify the characteristics describing medical students considering CAP as a possible career choice, we computed a logistic regression (Table 3). The overall model fit was accessed by Hosmer’s and Lemeshow’s χ², Nakelkerke’s R², and classification accuracy. Hosmer’s and Lemeshow’s χ² was 7.058 (df=8) indicating acceptable model fit. Nagelkerke’s R² was 0.50, signifying that about 50% of the variance in choosing CAP was explained by the regression model. Overall, 82.8% of medical students considering CAP as a possible career choice were correctly classified. General interest in CAP was the most important predictor. Prior experiences in the field of psychiatry were also relevant, with clinical courses in CAP being slightly more important than clinical courses in general psychiatry. Of the socio-demographic variables, only gender (p=0.035) and presence of family/acquaintances with CAP-related disorders (p=0.0498) were significant.

Our results show that German medical students have a high level of interest in basic CAP knowledge and consider it to be relevant to the work of physicians. One-quarter (25.4%) envisaged CAP as a possible career choice. This result is similar to that of a recent US study, which found 28% of medical students indicating strong interest in general psychiatry as a career choice (9). Both studies demonstrate the remarkable potential among medical students in these countries for recruitment into psychiatry and CAP. According to our study, the medical student who is a possible future CAP specialist is a woman and has previous experiences with mentally ill individuals, mainly through clinical clerkships in CAP or general psychiatry. The existence of relatives or acquaintances with CAP disorders was a significant predictor for considering CAP as a possible career choice. Although this predictor cannot be influenced by education, students’ awareness of relatives or acquaintances with CAP disorders can possibly be raised during CAP lectures.

Lessons for Future Recruitment Strategies

In our opinion, our results lead to four recommendations when aiming to recruit medical students into CAP. An early contact with CAP in medical school, high-quality clinical clerkships, the consideration and handling of negatives of CAP as perceived by medical students in the teaching process, and the implementation of family-friendly workplaces.

Early CAP Contact in Medical School

In our study, 54.8% of the students not considering CAP as a possible career choice had already made a definitive decision about their prospective medical specialty at the time of their first CAP lecture. As Martin et al. emphasized, ”if we are to recruit not only a greater number but also the best possible quality of physicians into our field, we must make concerted efforts to attract them into it early in their medical education” (21). Similarly, Dingle found a (nonsignificant) positive relationship between interest in CAP and early exposure to CAP (22). Sawyer et al. called for a longitudinal, developmentally appropriate approach to CAP education starting in the first years of medical school and continuing through the clinical years of medical school to residency and fellowship programs (23). Possible arrangements for early contact with CAP in medical school are described in the existing literature (21, 24).

High-Quality Clinical Courses

According to our results, the contact with mentally ill children during a clinical course was one of the parameters correlating best with CAP as a possible career choice. While our data allow no conclusion as to whether the positive attitude toward CAP was caused by the contact with patients or if there was a pre-existing preference for CAP, the data of Malloy et al. (25) point in the direction of the former hypothesis. In a post-clerkship survey, they found exposure to inpatient CAP to have a positive influence on students’ decisions to pursue CAP at the end of the clerkship. In any case, the results of our survey highlight the importance of involving medical students in CAP clinical courses (voluntary or compulsory) with high-quality teaching to maintain or develop their positive attitude toward CAP.

Consideration of “Cons” of CAP as Perceived by Medical Students

According to our results, the most critical drawbacks of CAP as a career choice for medical students are (in descending order) the challenges of collaborating with parents, an expected high emotional burden, a dislike of the patient population, a belief that treatment success is unlikely, a conviction that general medical training is not relevant, the perception of a lack of evidence-based treatment, and low potential earnings. In our opinion, it is important to deal with these issues when working with medical students. Strategies could include providing information on techniques to deal with noncompliant parents, professional coping strategies, presentations of a diverse range of patients and families, an emphasis on the scientific basics of CAP, and presentation of interdisciplinary pediatric/ CAP cases. Last but not least, students could be informed that career satisfaction within CAP is higher than average (26).

Family-Friendly Workplaces

A major goal for medical institutions should be to create family-friendly workplaces (e.g. daycare and kindergartens, option of part-time employment). There are two reasons for this: First, there is a growing desire both in male and female medical students for work–life balance, which includes time to bring up children (27, 28). Second, there is – at least in Germany – a growing number of women becoming physicians (62.8% of first-year medical students in 2007); (29) and – in the US – a constant trend of women selecting psychiatry in a higher proportion than men (30, 31). The high percentage of women (66.4%) in CAP lectures found in our study may be explained by this trend, but may also be due to a perceived image of CAP as a family-friendly working specialty (Figure 1).

Strengths and Limitations

The strengths of this study include the large sample and the multicenter approach. One weakness of the study is the possibility of a selection bias, as students with a special interest in CAP are more likely to attend CAP lectures. Another limitation is that individuals completing surveys often attempt to provide answers that are perceived as socially desirable. We tried to reduce this influence using an introductory paragraph in the questionnaire, emphasizing that the study focuses on the true and honest opinions of the participants and that data analysis is completely anonymous. Due to the limited number of items and the broad nature of most of them, the information gathered in this study is not as specific as would be preferable. On the other hand, a larger number of items might have reduced response rates. A comparison of our results to 1st-year students would be helpful to evaluate whether there is a change of attitude during medical school. Another interesting study design (which has already been applied by other medical specialties (28), would be to ask CAP trainees retrospectively which factors influenced their decision for CAP as a possible career choice.

To increase the number of CAPs, an optimization of recruitment strategies is compulsory. Many medical students choose their future subspecialty early during medical school. Therefore, recruitment strategies should focus on this area. An encouraging result of our study is that medical students in general have a positive attitude toward CAP and considered CAP basic knowledge to be relevant for their future work. This fact should increase the optimism of CAP teaching staff when working with medical students. Concerning the success of different teaching and recruiting strategies on medical students’ attitudes toward CAP and recruitment into CAP, longitudinal multicenter studies are needed to investigate these topics in an adequate manner. Using the positive potential for the most effective recruitment strategies could reduce the enormous shortage of CAPs. This will help to improve the mental health of children and adolescents in our societies.

The authors report no competing interests.

The realization of this study was facilitated by members of YIBcap (Young Investigators in Biological Child and Adolescent Psychiatry; www.yibcap.com).