Research on factors that potentially influence the choice of psychiatry as a medical specialty has been fueled in recent decades, especially in North America, by concerns about the decline of applicants to postgraduate psychiatric training programs. Comprehensive reviews of the relevant literature are now available (1—6), and information about applicants to psychiatric residencies in non-English-speaking countries has become available in recent years, although the data are more sparse (7—13). In this study, we examine the choice of psychiatry as a medical specialty among medical school graduates in Italy.
In Italy, in 1999, there were 335,761 registered medical doctors for a population of 57,613,000. The high ratio of physicians to general population (1:172) (14) makes underemployment common among physicians. Medical training lasts at least six years in Italy. Students usually undertake a psychiatric clerkship in the fifth year of training. Postgraduate training is a prerequisite for professional practice, and it has a variable duration; most training programs, including psychiatry, last four years. Reforms are being developed to apply new standards for postgraduate training courses (15).
The number of specialists in psychiatry in Italy was 6,471 in 1999, amounting to 3% of the specialized medical force (14). Since 1990, the Ministry of Health together with the Ministry of University and Scientific Research has specified the total number of new training positions for each academic year. Positions are filled through local admission examinations conducted at each of the 36 postgraduate psychiatry training schools in Italy. In terms of filling the available places, recruitment into psychiatry is not a problem in Italy, mainly because the number of medical students graduating each year exceeds the total number of residency slots available across all medical disciplines. For example, in 2000, a total of 14,224 medical doctors graduated in Italy, but only 10,718 new postgraduate training positions were available across all medical disciplines (of which 210, or about 2%, were in psychiatry). Each year this situation adds thousands to an ever-growing pool of medical school graduates who have not succeeded in entering a postgraduate training program.
Studies assessing attitudes toward psychiatry among medical students have used ratings as an index of the social perception of the discipline (16) or as a proxy measure of the likelihood of recruitment, either comparing results over time (11,17), comparing subjects from different countries (12,18,19), or comparing attitudes toward psychiatry with those toward other disciplines (20,21). Other researchers have used attitudinal surveys to demonstrate an improvement in ratings as a result of the psychiatric clerkship or particular modules of it, although this effect has been shown to be generally short-lived (22—25).
Recent studies in North America and the United Kingdom have compared attitudes between groups of subjects who stated an interest in psychiatry or chose psychiatry as a postgraduate discipline and subjects who did not. In their often-cited study of 204 senior medical students in Washington, D.C., Nielsen and Eaton (26) found that the group of students whose interest in psychiatry was stronger than average was more impressed than other students by psychiatry's comprehensiveness, the recent biological advances in psychiatry, and the efficacy of psychiatric treatments. This group was also more aware of the low status of the discipline within medicine, stigmatization by peers, and lower pay. These students were also less likely to view entering psychiatry as a waste of a medical education.
Scher et al. (27) reported results of a survey of 209 senior medical students from eight different U.S. medical schools, among whom 19 students stated a preference for psychiatric postgraduate training. Those intending to undertake a residency in psychiatry were more likely than their peers to rate more positively the efficacy of psychiatric treatments, the gratification from psychiatric work, the adequacy of psychiatric conceptual models, and the quality of the psychiatric teaching. They also appreciated the holistic approach psychiatry takes to patients, the opportunity to get to know patients in depth, the breadth of the field and its interactions with other disciplines, and its recent neuroscientific advances. They shared with students who preferred other disciplines the view that psychiatry is not as scientific as other specialties and that the public has a negative perception of psychiatry. In a study of 1,254 students from three U.S. medical schools by Perry et al. (28), the 187 students who were considering a career in psychiatry were more likely to be female, older, and white and less likely to have been undergraduate science majors. They had a more positive attitude toward direct patient care and toward the discipline itself and a more positive evaluation of the psychiatric teaching they had received. They also perceived less stigma for psychiatry than did their peers.
Lee et al. (29) compared the ratings of 26 senior medical students considering psychiatry as a career with those of 28 colleagues considering other specialties on a list of 38 factors. The psychiatry group rated 22 factors significantly more positively than did their peers. Among these, the 10 with the highest absolute scores for the psychiatry group were the perceived amount of intellectual challenge of the discipline, the number of novel and unique problems, emphasis on treating the whole person, the range of practice options in psychiatry, the psychiatric clerkship, biological advances in psychiatry, the possibility of a return to a humanities or social science background, the experience with the psychiatric faculty, the opportunity for long-term relationships with patients, and the emotional experience of working with psychiatric patients.
For this study, we decided to examine the attitudes of candidates for postgraduate training in psychiatry at four medical schools in the northern Italian region of Emilia Romagna and compare them with the attitudes of candidates for training in internal medicine. Each of the 97 candidates taking admission examinations for psychiatric training was given a survey questionnaire. Only 22 positions were available across the four schools. The psychiatry candidates were compared with internal medicine candidates at the Modena University School of Medicine.
Using findings reported in the literature and existing questionnaires (21,26,27,29,30), we developed a questionnaire to examine the factors that influence the choice of psychiatry as a specialization. We adopted the method developed in the Lee et al. (29) study as a model, and we included 19 items of their questionnaire (items 1, 2, 4, 5, 7, 8, 12, 14, 15, 17, 21, 24, 26, 29, 31, 31, 34, 36, and 37) in ours. The instrument (available from the authors on request), covers sociodemographic and academic data and information about the timing of candidates' decision to enroll for psychiatry or internal medicine. Respondents were also asked to rank which of three aspects of medicine they considered most important: research, relationship with patients, or diagnosis and treatment of diseases.
In the questionnaire, subjects were asked to rate each of 38 features attributed to psychiatry as a discipline on a 5-point Likert scale. The scale ranges from +2, indicating that the quality attributed in the item to the discipline exerted a very positive influence on their choosing postgraduate training in psychiatry, to —2, indicating that the cited factor had a very negative influence on their choice, meaning that they felt that the aspect had led them away from choosing psychiatry as a specialty. Finally, subjects were asked to consider all 38 items of the questionnaire and to rank the three that had the greatest influence on their choice for or against psychiatry. Questionnaires were distributed to 97 medical school graduates before they sat for admission examinations to all four postgraduate psychiatry programs in the Emilia Romagna region (at Parma, Modena, Ferrara, and Bologna Universities). The same questionnaire was administered to the comparison group, which consisted of 82 medical school graduates taking the admission examination for the internal medicine program at Modena University in the same academic year (2000—2001). Questionnaires were distributed to the candidates by one of the authors on the day of the examination, during the waiting period before the examination actually took place. Stamped, addressed return envelopes were provided. Return of a completed questionnaire was considered an implied informed consent. Questionnaires were kept completely anonymous. Ratings on factors from the two groups were analyzed for statistical significance using individual pairwise comparisons by employing two tailed t-tests, applying Bonferroni's method for multiple comparisons, and χ2 analysis was applied to categorical data. The data pertaining to the factors reported as most important in the choice for or against psychiatry were treated as descriptive.
Of the 97 candidates for psychiatric training, 52 returned questionnaires; four of these were excluded from the analysis because of missing data, yielding a response rate of 49.5%. Of the 82 candidates for training in internal medicine, 39 returned questionnaires, of which two were incomplete and excluded from the analyses, yielding a response rate of 45.1%.
In the sociodemographic information collected (t1), no significant differences were observed between the two groups in age, marital status, or religiosity. More women than men chose psychiatry, but this trend was not statistically significant.
The two groups did not differ significantly in secondary school background—that is, the proportion of subjects who had attended a liceo classico, a unique type of secondary school in Italy that has a special focus on classical humanities—or in their academic performance in medical school (t2).
The timing of the decision on what specialty to pursue differed markedly between the two groups. Around 60% of future psychiatrists had already made this choice before they had done the psychiatric clerkship, and 40% had made the choice before medical school. By contrast, only three subjects (8%) in the internal medicine group had made their choice before their clerkship in that specialty. In the psychiatry group, a substantially higher proportion than in the internal medicine group (54.2% versus 16.2%) considered their relationship with patients the most important aspect of the practice of medicine, whereas future internists were more likely to rate diagnosis and treatment of diseases as a more significant aspect (48.6% versus 20.8%).
Psychiatry candidates rated all 38 items on the questionnaire more positively than future internists, with the exception of item 26, which refers to the perceived status of psychiatry within the medical faculty. This was the only item for which the mean rating was slightly, although not significantly, less negative for the internal medicine group. Thirteen of the psychiatry group's ratings were significantly higher (p<0.05) than those of their colleagues (t3).
The leading five features among the items selected by the future psychiatrists as determinants for their choice of specialty were, in rank order, the amount of intellectual challenge of the discipline (N=27), psychiatry's emphasis on the patient as a whole person (N=17), the opportunity to cultivate an interest in the humanities (N=11), the original and unique topics encountered in psychiatry (N=8), and the importance of social and relational issues in the discipline (N=8).
On the other hand, the most important factors chosen by future internists for rejecting a career in psychiatry were the perceived (low) possibility of using their medical training fully (N=11), the perceived (low) efficacy of psychiatric treatments (N=9), the intensity and quality of emotional contacts in the discipline (N=7), the experience of psychological problems, either personally or by a relative or close friend (N=4), and the possibility of getting to know unexplored aspects of self through work with patients (N=4). Interestingly, comments by respondents in the psychiatry group confirmed the personal interest in learning to master aspects of oneself through working with patients (for example, "What drives me to psychiatry is the possibility of facing my fears of losing control") and underscored the possibility of being more creative in therapy than in most other medical disciplines (for example, "It's the only discipline where the doctor is not constrained step by step by a silly flow chart"). A future internist wrote: "Someone who works with crazy people all the time becomes crazy too."
This study had some methodological limitations. Because of the low response rate for both groups, the small sample size, the regional scope of the research, and the large number of comparisons made (even though the Bonferroni correction was used), any generalization of the findings must be considered tentative. However, a methodological strength of the study was the comparison of groups of medical school graduates taking admission examinations to residency programs in psychiatry and internal medicine—that is, subjects who had made a definite commitment to a specialty. This aspect of the study overcomes limitations that might arise from using first-year or midcourse medical students, who are less certain of their later training choices, as suggested by Zimny and Sata (30).
One of the most interesting results of this study is the precocity of the commitment to the discipline shown by psychiatry candidates. Other researchers have reported variable results on the timing of the choice of psychiatry as a specialty. In Kritzer and Zimet's (31) study of 120 residents, 45% of those entering psychiatry indicated that it was their first choice on entering medical school. In Cameron and Persad's study (32), only 14% of the 93 Canadian psychiatry residents had decided on a career in psychiatry before entering medical school; this group was also a minority in the Mowbray et al. study (2). Babbott et al. (33), examining the postgraduate career choices of U.S. medical school graduates in 1987, found that more than 30% of those who selected psychiatry had made the decision early. The early arrival at this decision in comparison with students who chose other specialties has been reported in other studies as well (7,28).
The presence of a considerable pool of students entering medical school with a preference for psychiatry suggests that early recruitment strategies might be effective in channeling such students into the field. In effect, despite the finding that a significant fraction of medical students change their choice of specialty during and after medical school, the choice of psychiatry as specialty has been found to be a fairly stable one (34). Weintraub et al. (35) and Clardy et al. (36) have suggested that it could be worthwhile for psychiatric residency program to start aggressively recruiting students who had already expressed an interest in psychiatry before the psychiatric clerkship. Our results seem to support this view.
Next to the timing of the choice, the positive impact of experiences of mental illness or psychiatric treatment personally or by relatives or close friends, as others have found (30,32), can suggest an "early vocation" to psychiatry in many candidates. The complexity, the originality, the amount of intellectual challenge, and the variety of psychiatry as a field are appreciated by both future internists and future psychiatrists, although significantly more so by the latter. Similarly, future psychiatrists are more appreciative of the holistic, humanistic, dialogic, and hermeneutic tension of their chosen discipline, although these were also positive factors for their colleagues who chose internal medicine in our study as well as in other studies of medical students (7,10,12,13,17,18,26,27,29).
The direct comparison of the ratings of the 19 items drawn from the Lee et al. study (29) shows a substantial overlap of attitudinal ratings among Italian and U.S. medical school graduates. For these shared items, of the 14 that were rated significantly more positively in Lee's psychiatry group, 10 were also rated more positively in our samples, although not all to the level of statistical significance; the exceptions were the favorable impact of the psychiatric clerkship, of the opportunity for long-term relationships with patients, the perceived pace of growth of the discipline, and the recent biological advances of psychiatry, which did not differentiate the two groups in our study but did in that of Lee et al. In our study, experience of mental illness personally or by relatives or close friends, as noted, did exert a differential positive influence on the choice of psychiatry that was not found in the Lee et al. survey.
The analysis of our data shows that the motivational forces underlying the choice of psychiatry appear to be marked by curiosity distributed across different levels pertaining to the discipline. First is the interest in the intrapsychic dimension of the relational and affective interplay with patients (factors 4, 5, and 12), including a fascination with the enigma of mental illness (factor 6). Second is the overt desire for knowledge that is not only general (factor 1) but ranges from the experimental method (factor 35) through various aspects of psychiatric practice: psychotherapy, the narrative perspective of the discipline, and the variety of specific interventions (factors 3, 13, and 38).
Other studies have found that future psychiatrists place more value on the possibility of doing research than do their colleagues in other specialties (2,29), and nurturing this preference is certainly a task educators should pursue. Furthermore, future psychiatrists seem to have a greater desire for a deep emotional contact with patients (factor 12). In our study, psychiatry candidates were similar to their future internist colleagues in considering psychiatry not to be a high-status field, and this finding is in line with other researchers' results (7,9,23,26,27,29, although recent studies suggest a trend toward improvement (12,17). When it comes to the depth of the evidence base, the efficacy, and the variety of psychiatric treatments, the future psychiatrists in our study clearly differed from their internist colleagues in valuing these factors in their choice of specialty, another finding that confirms earlier results (7,27,29). Perhaps this difference arises because medical and formal psychiatric teaching has failed to shift the views of future internists, or, if that has happened, the gain hasn't been retained over time (22—25). In fact, the future internists seem to retain the old cliché of the incurability of mental disorders ("semel mente captus, semper mente captus"), whereas future psychiatrists appear to have addressed this problem precociously "from inside," in many cases having already rejected this prejudice for personal reasons even before entering medical school. As Feifel et al. (21) pointed out recently, there is room for educators to dispel these prejudices with sensitive and committed teaching.
The suggestions that may be drawn from this study appear to be twofold. In regard to medical school teaching, educators should emphasize the available evidence of the efficacy of various biological and psychotherapeutic treatments for "primary psychiatric" patients. Through exposure to consultation-liaison psychiatry experiences (37,38), they could demonstrated the usefulness and importance of basic psychotherapeutic skills, which can be applied to all "medical" patients as well. Involvement with not only the acutely disturbed psychiatric inpatients but also with outpatients who represent "successful" cases, as suggested by Clardy et al. (36) and Pessar (39), may challenge commonly held pessimistic attitudes and may contribute toward inspiring a more positive attitude in future practitioners who choose disciplines other than psychiatry.
Regarding postgraduate training in psychiatry, the major responsibility is to develop awareness, respect, and nurturing of the "great expectations" of psychiatric candidates. Above all, efforts should be made to challenge factors that can frustrate and discourage the strong curiosity of these students—namely, cynicism, prejudice (21), intellectual stereotypes (40), early burnout, and dehumanizing defensive attitudes—thus allowing the transformation of the intellectual challenge into a direct and hopeful engagement.
The authors thank the following medical schools involved in the study and the directors of the involved residency programs: University of Modena and Reggio Emilia (Alberto Albertazzi, M.D., Cesare Carani, M.D., Giorgio Mattioli, M.D., Maria Grazia Modena, M.D., Erica Villa, M.D.), University of Parma (Carlo Maggini, M.D.), University of Ferrara (Emilio Ramelli, M.D.), University of Bologna (Giuseppe Ferrari, M.D.). They also thank Pietro Faglioni M.D., who assisted in statistical analysis, and Kathryn Elkins, B.A. (Hons), who revised the English version of this paper.