The study by Fischel et al. (1) did not find a significant change in attitudes toward psychiatry between the beginning and the end of their psychiatry clerkship in two small groups of medical students, one in Israel and one in New York City. The authors state that “the lack of change probably in part explains why psychiatry has such poor recruitment.” This conclusion probably shook up a bit many educators who read this article. No matter what we do, what we teach, and how we do it, we are basically doomed and students do not like us! But is it really true, and can the authors make such a conclusion based on their results? Is this just another of many simple answers to a very complex issue?

First, let us look at how applicable the results of this study (1) are and whether they fully warrant this negative conclusion. The number of medical students in this study was fairly small (N=57). We do not know whether this number represents one rotation, two rotations, or the entire class. None of the questions of the questionnaire used asked directly about either student career choice or definite attitude toward psychiatry. It would be important and interesting to ask students an additional question at the end of the clerkship. Questions like the following would probably yield interesting answers. “Did your experience during the clerkship change your view of psychiatry as a discipline?” “Did your clerkship experience influence the likelihood of choosing a career in psychiatry?” The latter was asked in the study by Niedermier et al. (2). Many studies, including ours (3), unfortunately do not ask these questions. We psychiatrists seem to like to beat around the bush instead of hitting the nail on the head. Nevertheless, the results of this study cannot be generalized but could serve as a warning: at times, psychiatry clerkship may not provide what we wish for.

Second, what is the evidence in the literature for the impact of the psychiatry clerkship on the medical students’ attitude toward psychiatry and psychiatry as a career choice? It is a definitely mixed bag. Many studies cite a positive influence of the psychiatry clerkship on students’ attitudes toward psychiatry. Weissman and Bashook (4) found that almost two thirds of psychiatry residents in their study rated the clerkship experience as the most important medical school influence. Sierles and Taylor (5) list (with references) numerous clerkship factors believed to enhance recruitment, such as active student participation in patient care, enthusiastic supervision, well-defined student roles, seeing treatment as effective, senior faculty involvement, having good residents who enjoy their work, and quality but not length of the clerkship. Two recent studies (2, 6) reported either no significant impact of clerkship on the students’ willingness to consider a career in psychiatry (6) or that the rotation significantly influenced medical students’ decision not to choose a psychiatric career (2). However, the students in the latter study (2) ranked inpatient and outpatient experiences as helpful, and students with an initial neutral view of psychiatry developed predominantly positive attitudes at the end of their rotation. The second study (6) did not truly test the attitudes toward psychiatry but, rather, attitudes toward mental disorders, treatments, and the importance of working with families.

The reader may ask, “What does all this mean and what does one do with all this information?” Most of the studies mix the impact of the clerkship on attitudes toward psychiatry and on psychiatry as a career choice. These two need to be separated in further studies, as they do not address the same issue. It seems to me that the answer to the question posed by the authors of the present study (1), “Does a clerkship in psychiatry contribute to changing medical students’ attitude toward psychiatry?” is yes, it does. Most people would agree that the clerkship has some impact on attitudes toward psychiatry and that the impact on recruitment to psychiatry is not always clear. However, the “yes” answer that the clerkship experience contributes to changing students’ attitudes does not say much about the quality of the impact. It is obvious that we need to know more about the quality and character of this impact. Thus, we need to go beyond the question of whether the clerkship influences the attitudes and possible student career choice. The questions we really should and need to ask are:

How does the psychiatry clerkship experience influence attitudes toward psychiatry or career choice?

What makes or could make this experience a positive one?

What clerkship factors and/or experiences positively influence students’ attitudes and/or career choice of psychiatry?

We know, or believe that we know, the answers to these questions intuitively, but we do not always have hard evidence or scientific data. The experience of a clerkship has to be a positive one, because otherwise the influence of the clerkship on career choice of psychiatry is going to be none or negative. Thus, we need to figure out what makes the experience positive and how to make it positive (I am leaving out the question “Do we have the resources/means to make it a positive experience?”).

Do we have any data? The mentioned review article by Sierles and Taylor (5) reviews many factors that have been found (or thought) to have a positive impact on recruitment or attitudes toward psychiatry. Another article by Sierles et al. (7) provides data on more factors affecting one’s career choice. Many of us remember numerous examples of medical students being influenced by a good resident, an interesting set of patients, or an enthusiastic faculty member. I would argue, however, that this evidence is merely observational, a bit akin to case reports, case series, or cohort studies in other areas of research. I would also argue that to provide a better understanding of fairly complex issues, the research on psychiatric education has to become more sophisticated. Education research has to move from mostly observational studies to “interventional studies” (akin to randomized studies in other areas of research) to be able to better understand what works and what does not. Educational research should also move to multicenter or multisite studies (e.g., the study by Balon et al. [3]) to increase the number of subjects and to study individual and local variations and factors.

An example of what I mean by interventional research on psychiatric education is a small recent study (8) in which about half of students rotating through psychiatry were required to attend a brief presentation during which they received a handout on the positive aspects of child and adolescent psychiatry (which the other 51% students were not given). Students exposed to this presentation reported increased knowledge of the shortage of child and adolescent psychiatrists and more accurate incomes at the end of their clerkship. However, the presentation did not increase students’ interest in practicing child and adolescent psychiatry. This study tells us, at least, what one small intervention influenced and what it did not influence.

We can only hope that such studies, with various interventions and at various sites, will be done, and that we will be able to achieve a better understanding of the complex issues and cope with the potentially negative results.

The last caveat of this entire discussion touches a bit on an ethical dilemma. The issues of who is responsible for what, and why he or she is responsible for it, has been left out of the debate. For obvious reasons, our field has been a bit obsessed with recruitment and what influences it and attitudes toward psychiatry. However, we do not discuss whether the clerkship should really serve as a recruitment “tool” (which is different from what should be taught during the clerkship to all students). We are also not clear about who should be responsible for the “positive impact” and “positive roles” and improved recruitment. Is it the role of the clerkship director? Training director? Chair?

In conclusion, it seems that the psychiatry clerkship, in spite of the presented study (1), has an impact on medical students’ attitude toward psychiatry. The impact of the clerkship on the students’ career choice is less clear. We need to develop more sophisticated studies to fully evaluate the impact of clerkship and to correctly determine the factors positively or negatively influencing students’ attitudes and career choice.