The last three decades saw a progressive decline in the proportion of U.S. medical school graduates choosing to be psychiatrists (1), although recently Sierles et al. (2) reported on modest increases in recruitment for most specialties, including psychiatry, during the period between 1998 and 2002. Only 4.5% of the approximately 90 Tel-Aviv University Sackler Faculty of Medicine (TAU-FM) graduates chose psychiatry as residents, while during the preclinical stage one third reported psychiatry as a possible choice for their future area of expertise (3, 4).
Choosing a field to specialize in encompasses a multidimensional process which contains several aspects, some unknown to us. Sierles et al. (1) described it as interplay between extrinsic factors (such as national trends) and intrinsic factors, which include the quality of education in the various medical departments and programs. Other variables affecting residency choices may emerge prior to starting medicine school (5), such as demographics, social variables, achievements, and interest in the field, and during the intramedical school period, such as attitudes toward psychiatry, and the psychiatrist’s image as perceived by the medical student and accumulated experience during medical education. Sierles et al. (6) showed that the experience acquired during medical school affects career choices. Nielsen (7) suggested that the quality of psychiatric education in a particular psychiatric clinical center is a significant factor in the process of choosing psychiatry as a medical specialty.
Thus one may conclude that psychiatric education during medical school is a critical factor in choosing psychiatry as a career. The negative attitude toward psychiatry stems, in part, from misconceptions which could be corrected by the medical studies program (5). These misconceptions result from the negative social stigma that prevails toward the psychiatric profession in general, its practitioners, and patients. It appears that exposure to the profession of psychiatry is a meaningful contributor to the positive attitude of medical students in this area of expertise. To this end, the impact of the clerkship was shown to be positive (8). Recently, Galka et al. (9) showed that a rotation in psychiatry did not change students’ attitude toward the options of a career in psychiatry, but did affect students’ perception of mental illness and their awareness of social and biological factors’ involvement in its etiology.
The Geha Mental Health Center in Petach-Tikva, Israel, which is affiliated with TAU-FM, has a structured psychiatry clerkship program. Students undergo 5 weeks of diverse psychiatric experience (open ward, closed ward, adolescents, toddlers, outpatient clinic, etc.) during which they are under tutelage; at the end of the day they attend a frontal lecture or discussion emphasizing clinical aspects (a total of 200 hours: 75% in clinical exposure, 25% frontal lectures and discussions).
The objective of the present study was to asses the impact of the psychiatry clerkship program on the attitude toward psychiatry of native Israeli students and U.S. students studying in Israel. We hypothesized that both student groups would be impacted positively by this program.
We interviewed two groups of medicine students (ages 23–27 years) from TAU-FM who attended the psychiatry clerkship program at Geha Mental Health Center during each of two consecutive years. The two groups consisted of Israeli TAU-FM students (N=29; 14 males) and of U.S. students (N=28; 18 males) studying in Israel at the Tel-Aviv University, Sackler Faculty of Medicine’s New-York program (TAU-FM-NY). The TAU-FM-NY students are mostly of Jewish origin who were educated in the United States.
In this prospective study, a modified short version of Nielsen’s questionnaire (7) was administered to the students at the start of the clerkship and again on its last day. This questionnaire was chosen because its 10 questions covered three relevant thematic subjects: knowledge in psychiatry (items 1, 3, 10), beliefs about psychiatry and mental health professionals (items 2, 5, 6, 7), and intent and purpose in psychiatry (items 4, 8, 9). Each question had four possible answers: strongly disagree, disagree, agree, and strongly agree (Appendix 1), and was scored 1–4, respectively. A low score implied a negative attitude toward psychiatry. Students were asked to participate voluntarily, and anonymity was kept. Answering the questionnaire was considered as consent to take part in the study.
We used two-tailed paired and unpaired Student’s t test to assess within and between-group differences. Significance was set at p<0.05. Bonferroni’s correction was used appropriately.
Clerkship did not affect either the Israeli or the U.S. group’s average score, (before versus after: 27.14±2.97 versus 27.24±3.51, t=0.15, p=0.88, n.s. and 28.53±2.27 versus 29.14±3.72, t=0.85, p=0.4, n.s., respectively).
No significant difference was obtained when comparing the average changes between start and end of clerkship scores between the two groups (Israeli=0.1±3.7; U.S.=0.6±3.78, p=0.61, n.s.). The same was true for the comparison of the average difference between start and end of clerkship scores by gender in total population of students (males=0.094±4.44; n=32, females=0.68±2.56; n=25, p=0.56, n.s.).
The item analysis between start and end of clerkship are shown in Table 1. Since there were no significant differences between the two groups the data were pooled and not analyzed by country. Statistical significance was noted on items 1, 4, and 5 but this was lost following Bonferroni’s correction (Appendix 1). Scores and differences, when clustering the scores into three major thematic groups (knowledge in psychiatry, beliefs toward psychiatry and mental health professionals and intent and purpose in psychiatry), are presented in Table 2. The data show no significant changes were observed following the clerkship in the three thematic clusters for the total study sample.
Our data show that overall there was no statistically significant change in either the Israeli group between the start and end of clerkship scores, suggesting that the clerkship did not affect their attitude. The lack of change probably in part explains why psychiatry has such poor recruitment.
Item analysis demonstrated no significant difference (following Bonferroni’s correction) on any of the thematic clusters of the questionnaire, namely knowledge in psychiatry, beliefs toward psychiatry and mental health professionals, and intent and purpose in psychiatry.
Social stigma and false beliefs regarding mental illness may influence students’ attitude toward psychiatry, and, in turn, their willingness to choose psychiatry as a career. These factors, which are frequently determined before the start of clerkship, showed minimal change at the end of clerkship, but our study lacks long-term follow-up to explore the students’ position after graduation.
Our observation of lack of change in students understanding of the biological factors of mental illness during clerkship is not consistent with other studies (9, 10), which showed that students’ attitudes were changed after clerkship in that they attributed the etiology of mental illness to both biological and environmental/psychological factors. The recognition of psychiatry as a legitimate branch of medicine, with regard to etiological factors and management, could probably be affected by such a change. Our findings show that students’ preclerkship attitude toward psychiatry was fairly high and is in concordance with data by other study (4) showing that Israeli students in preclinical years consider psychiatric residency in higher proportions than U.S. students (38% versus 7.7%); psychiatry was most attractive when intellectual challenge was considered. In concordance with that, Niedermier et al. (10) showed that the majority of students appeared to have favorable attitudes at the beginning of the clerkship in the United States.
It should be noted that students’ origin (i.e., Israeli or U.S.) did not affect the results of the study. This finding may suggest that clerkship impact is not a matter of origin. However, generalizability of this is questionable since U.S.-born students in this study are from a specific ethnic/cultural background (most of them are of Jewish origin). This is somewhat different from the results of another study (6) comparing medical career choice in the United States between international medical graduates and U.S. medical schools graduates. That study found a higher proportion of international medical graduates choosing psychiatric residency, thus implying an effect of students’ origin on career choice. However, the significance and generalizability of this finding is unclear, and the relationship to psychiatric clerkship was not evaluated.
Our study is limited by its small sample size and the fact that U.S. origin students come from the same ethnic background, which limits the study generalizability.
Our data show no impact of the psychiatry clerkship on medical students’ attitudes toward psychiatry, according to the dimensions examined, with the result not affected by the students’ origin (Israeli or U.S.). Other dimensions and factors that may be influenced by the psychiatry clerkship should be explored in order to enhance the clerkship program by providing appropriate directions and by identifying possible clerkship-dependent contributors to the positive perception of psychiatry. Another interpretation could be that the psychiatric clerkship needs to incorporate elements of subjective experience with unorthodox methods of tutoring, such as elaborated personal responsibility of patients’ management, participation in psychodynamic groups, and ventilation of experiences and difficulties.