Medical students appear to modify their attitudes and opinions toward different specialties as they go through medical school (1, 2). A negative attitude toward psychiatry or the psychiatrist’s role has frequently been observed by a number of authors in different countries [U.S. (1, 3—7), the U.K. (8—10), France (11), Australia (12, 13), Saudi Arabia (14), Korea (15), and China (16)]. The most common complaints relate to the lack of scientific rigor in psychiatry, the nonefficacy of treatment, and the psychiatrists’ low social status among physicians. Furthermore, it is accepted that there are considerable difficulties in attempting to modify these negative attitudes during the process of medical training (8, 16—18).
Factors that influence such attitudes directly can be classified according to three main categories: individual factors, factors related to medical school, and sociocultural factors. The first category includes specific characteristics of the subject, such as being female (2, 7—8, 19—21),personality characteristics (2,7), previous experience with mental illness (11,19), and interest in becoming a psychiatrist (2, 4, 8, 10, 16). In the second category, which includes factors related to the department of psychiatry delivering training, the most important is the contact that the students have with psychiatric patients (2, 6, 10, 11, 19, 21—24). Other factors include the relationship with those involved in the training in psychiatry (1, 4, 25) and the prestige of the department (26). It also seems that students voice less favorable opinions in the presence of nonpsychiatry staff (4, 6) and during surgical and family medicine internships (9, 15, 25). The third category relates to wider external factors that seem to depend on geographical and historical events influencing the present (7, 14, 22).
Some authors (3, 22) believe that the general opinion of psychiatry is gradually improving, together with its social image in general. According to some U.S., British, and Australian studies, the percentage of students choosing psychiatry as their future specialty has decreased considerably (2, 3, 6, 9, 13, 27,28), although it has lately increased reasonably from 3.5% in 1999 to 4.5% in 2003 (National Resident Matching Program 2003 Match Data). Although the causes for this decrease cannot be certain, it may be presumed they are multifactorial (2, 3) and that the U.S. students’ views and opinions toward psychiatry after their clerkship only partially explain the low percentage of residents in psychiatry (3).
The subjects included in our study were chosen at random from the School of Medicine at the Universitat Autònoma de Barcelona (Autonomous University of Barcelona). According to a cross-sectional design, a questionnaire based on that by Nielsen et al. (6) adapted by Balon et al. (3) and translated from English into Catalan, was administered to all the students. For the comparison, data from U.S. students were obtained from the results of the study done by Balon et al. (3).
We chose these two groups with the hypothesis that comparison of two different countries with different teaching approaches to psychiatry could help us gain a broader view about the complex process of recruitment in both countries. In our university, the psychiatry course consists of a total of 100 hours (6 weeks during the fourth year): 35 hours of theory lessons and 65 hours of practice rotation. In the U.S. the psychiatry course generally consists of 4—8 weeks during the third year. We presumed that these formal differences were not complicating and complex enough to influence a possible change of attitudes among both groups.
Balon et al.’s questionnaire consisted of 39 questions, 29 of which explored the attitudes of medical students toward psychiatry according to six aspects: 1) overall merits of psychiatry, 2) efficacy, 3) role definition and functioning of psychiatrists, 4) possible abuse and social criticism, 5) career and personal reward, and 6) specific medical school factors. Multiple-choice responses to each item were defined as follows: "strongly agree," "moderately agree," "moderately disagree" and "strongly disagree." Four questions were included in order to record demographic characteristics such as sex, age, academic year, and choice of medical specialties. A written explanation of the purpose of the study preceded the main questionnaire.
The only formal criterion required to participate in the study was to have completed a theoretical and practical psychiatry course as in the Balon et al. study (3). Students were given an oral guarantee that their responses to the questionnaire were absolutely anonymous and that neither academic, nor social risks, would be consequent upon their agreement to participate. In view of these conditions, returning an anonymous questionnaire was considered to be indicative of informed consent.
The statistical analysis was performed using a Macintosh Power PC 7600/120 and the program Statview 5.0. Due to the existence of missing data for a number of questions in a few subjects, the descriptive analysis of the attitudes’ items were converted to relative percentages, ignoring unanswered items. Data from every question answered by Spanish and U.S. students were compared using a chi-square test with three degrees of freedom (the questions allowed one of four responses). We applied Bonferroni and Sidàk in order to correct the bias due to multiple comparisons.
Selected Demographic Characteristics
The index group consisted of 151 students: 49 men (32.7%), 101 women (67.3%), and one student did not state their gender. The mean age was 22.4 years (SD=1.14). Out of the 151 students who answered the questionnaire, 93 did it during the 1997—1998 academic year and 58 students did it during 1998—1999.
The students indicated their preferred choice of specialty as follows: internal medicine: 27.1% (N=41), pediatrics and its subspecialities: 11.3% (N=17), family medicine: 10.6% (N=16), surgery and surgical subspecialties: 9.2% (N=14), obstetrics/gynecology: 7.3% (N=11), psychiatry 6% (N=9), neurology: 4.6% (N=7), ophthalmology: 3.3% (N=5), anesthesiology: 2.6% (N=4), dermatology: 2% (N=3), emergency medicine: 2% (N=3), diagnostic radiology: 0.7% (N=1), pathology 0.7% (N=1), and "none of the above": 8.6% (N=13). Six (4%) students were undecided.
Attitudes and Views About Psychiatry
Overall merits of psychiatry.
As seen in t1, most of the Spanish students were positive about this aspect, and their opinions were significantly different from those expressed by the U.S. students. Spanish students were less likely to consider that psychiatry is making advances in the care of mental disorders or expanding at the frontiers of medicine (question 1: χ2=26.42, df=3, p<0.0001; question 2: χ2=27.84, df=3, p<0.0001). However, Spanish students contrary to U.S. students, were not of the opinion that psychiatry is imprecise and unscientific (question 3: χ2=20.25, df=3, p=0.0002).
As seen in t2, students from the U.S. were more likely to consider that psychiatric treatment is beneficial for medical or surgical patients and the differences in this view were statistically significant (question 5: χ2=29.92, df=3, p<0.0001).
Role and function of the psychiatrist.
As seen in t3, this aspect presented a certain disparity in the points of view expressed among Spanish students, whilst the U.S. students were more homogeneous in their views. A significant proportion of Spanish students neither regarded psychiatrists as clear, logical thinkers, nor considered that they had the most authority and influence among mental health professionals (question 8: χ2=42.72, df=3, p<0.0001; question 10: χ2=32.63, df=3, p<0.0001). Similarly, Spanish students felt more strongly that psychiatrists are too apologetic when teaching and that "psychiatry is too biologically oriented" (question 11: χ2=14.78, df=3, p=0.002; question 12: χ2=21.01, df=3, p=0.0001).
Possible abuse and social criticism.
As seen in t4, most of the Spanish students did not think that psychiatrists abused their legal powers; indeed, as many as 21% of the sample stated quite the opposite, a finding that made their views significantly different from those of the U.S. sample (question 14: χ2=37.44, df=3, p<0.0001).
Career and personal reward.
As seen in t5, Spanish students agreed that psychiatry has low social prestige, a view that was significantly different from that expressed by the U.S. students (question 16: χ2=24.03, df=3, p<0.0001). Concerning feeling supported in their choice of psychiatry as a specialty, Spanish students felt less influenced by family, friends, and fellow students, and they were less likely than U.S. students to fear that they might be regarded by others as odd, peculiar, or neurotic (question 20: χ2=14.43, df=3, p=0.0024; question 21: χ2=39.67, df=3, p<0.0001, question 22: χ2=29.95, df=3, p<0.0001).
Specific medical school factors.
As seen in t6, Spanish students were less satisfied than U.S. students with the quality of teaching, with the role models they were presented with during the psychiatry rotation, with the extent to which psychiatrists appeared to be logical thinkers and with the few efforts made to encourage them to become psychiatrists (question 24: χ2=49.98, df=3, p<0.0001; question 26: χ2=43.87, df=3, p<0.0001; question 27: χ2=44.98, df=3, p<0.0001; question 29: χ2=22.42, df=3, p<0.0001). However, they agreed more than U.S. students that psychiatry was respected by nonpsychiatry staff (question 28: χ2=32.27, df=3, p<0.0001).
In general, Spanish students’ attitudes and views regarding psychiatry were positive. These findings, therefore, corroborate the results of Balon et al. (3) and Garyfallos et al. (22) that opinions of psychiatry have improved. A comparison with the published results (3), however, reveals that Spanish students showed a difference in the attitudes to the discipline of U.S. students, especially in some questions relating to the biopsychosocial concept of illness, salary, social pressure, and respect from nonpsychiatry staff. Although these factors affect recruitment in a very complex way and the explanations of the difference are speculative, they seem to have influenced the students’ choice of psychiatry as their selected specialty.
Many Spanish students said that psychiatry was not an expanding frontier of medicine. However, Spanish students significantly regarded psychiatry as a more scientific and precise specialty than other specialties (72.9% versus 56.1%). Although concerning efficacy Spanish students agreed more with the usefulness of psychiatric consultation for nonpsychiatry patients, they did not give as much importance to the functioning of the psychiatrist as U.S. students; about a third said that most psychiatrists are not logical thinkers (37.1% versus 17.9%), that psychiatrists have the same authority and influence as other mental health professionals, that they are too apologetic when teaching psychiatry, and that psychiatrists abuse their legal power. Finally, Spanish students preferred, with significant differences, a psychiatry both more biological and more attentive to the patient’s psychological problems.
With a view to career choice, Spanish students were more inclined to see psychiatry as having low social prestige. However, Spanish students seem to be subjected to fewer additional external pressures when making their choice of specialty; these pressures include family (14.9% versus 25.3%), friends (20.4% versus 33%), and fellow students (34% versus 41.5%). Opinions concerning standards of teaching were significantly lower among the Spanish students (48.3% versus 73.8%), and they also reported receiving less encouragement to enter psychiatry (49.6% versus 69.1%). Nonetheless, they reported a greater respect for psychiatry among nonpsychiatry staff (71.7% versus 54.5%).
The interpretation of our results might have been improved had we used direct comparisons in order to obtain them. A limitation of the paper is that the results were obtained only at one medical school, and our findings might not necessarily apply to the Spanish medical school population as a whole. Another limitation may have been caused by the necessity of translating the questionnaire into Spanish, which may have unwittingly changed the meaning of some questions and thus led to a distortion in the replies. Furthermore, it is possible that there are some differences in the way that certain aspects of psychiatry are perceived in both countries, which was not reflected in the translation. However, we believe that the anonymous and multiple-choice questionnaire used by Balon et al. (3) gives a fair reflection of students’ perceptions of psychiatry.
As we mentioned above, some authors have stated that the global opinion of psychiatry has improved. The interest in psychiatry among U.S. medical students is still low even though there has been a slight increase from 1998 to 2003. There is no agreement among the different authors about the causes of this low recruitment, which include: the high biological influence in the specialty nowadays; the lower income prospect in comparison with other specialties; and the competition between psychiatry, psychology and social work students (2, 3). Other causes could be the negative social pressure made by colleagues and nonpsychiatry staff in the medical schools (6) or the inability of psychiatry to change society through medicine (3).
It seems that the differences in the attitudes and views of psychiatry between Spanish and U.S. students could have influenced the process of recruitment. The number of students choosing psychiatry as their future career was 6% in our study. This percentage is significantly higher than the percentage nowadays in the U.S. (4.5%). The high percentage of Spanish students who want to do psychiatry might be due to the fact that they did not experience the possible causes of decline in U.S. to the same extent. Approximately 14% more Spanish students than U.S. students felt that psychiatry is too biological and that psychiatrists earn as much money as other specialists. They believed that their friends and nonpsychiatry staff respected their decision of becoming psychiatrists in almost 8% and 17% more than U.S., respectively. Therefore, it could be some wider external factors such as cultural issues such as feeling more supported when choosing psychiatry.
Another possible cause for this high percentage related to our department could be that Spanish students attend medical school at an earlier age than U.S. students, which could make the biopsychosocial training schemes available sooner. In addition, our classes focus particularly on an influential interaction between students and psychiatrists, which was stated as particularly important by some other authors (4, 29).
The process for choosing a residency position in Spain differs from that of the U.S. since it is determined by an official exam and by the number of residency positions offered by the Ministry of Health. During the last decade the number of residency positions for psychiatry has increased by 33%. During the year 2002/2003, 2.9% of the total of 5,496 residency positions offered were in psychiatry, making it the eighth most frequently available specialty (Ministry of Health). This means that despite the increase in the number of positions, 51.7% of the students who expressed an interest in psychiatry after their fourth year of medical school in our study were not able to enter psychiatry on completion of their studies. As Brook pointed out in 1983 (25), a part of these students were more likely to end up in family medicine positions, which is the specialty with most residency positions available (32.3% of a total of 5,496 positions offered in 2002—2003).
Therefore, the recruitment process is not a priority in psychiatry training in Spain since the Ministry of Health offers the psychiatry positions according to the laws of supply and demand. Because Spanish medical students are not guaranteed a psychiatry residency position as in the U.S., psychiatry might be regarded as a more valuable specialty among Spanish students.
Medical student career choice of psychiatry in the U.S. was at its highest during the 1950s to the mid-1970s, when studies showed that students tended to view psychiatry as more unscientific and imprecise and having less prestige than they view psychiatry nowadays (30—32). It seems, therefore, that U.S. students chose psychiatry even though they were very aware of the speciality’s weak points. There seems to be higher recruitment both in Spain and in the U.S. when the students’ opinions are more critical. This could be due to the fact that being more critical leads to a better understanding and stronger desire to choose the specialty. Or could it also be that recruitment has nothing to do with attitudes toward psychiatry after all?
Further research should focus on the following issues: 1) longitudinal studies on the factors influencing the process of choosing a specialty all the way through medical school, 2) more studies comparing the opinions of students toward psychiatry and the percentage of students choosing it, and 3) differences in the recruitment process and its consequences in Spain and the U.S.
The authors thank Ana-Luisa Subirà Cuyàs for her help in translating this article into English.