Many of the developing countries are facing a shortage of psychiatrists, and Pakistan is not an exception. The World Health Organization (WHO) Mental Health Atlas 2005 (1) gives an estimated number of psychiatrists of 4.15 (SD=6.07) per 100,000 globally. There are about 350 psychiatrists in Pakistan, a country of 150 million, or 2.8 psychiatrists per 100,000 people (1).
Medical school graduates are the source of the country’s physicians. Their choices determine the manpower distribution in various specialties. Assessing how these graduates choose their areas of specialization is essential to achieve a balanced distribution of doctors among all specialties (2). Researchers have approached this question from different perspectives. Feifel et al. (3) reported that out of 223 freshmen surveyed from three medical schools, only one student identified psychiatry as the career of choice in the United States However, most of the students valued interpersonal interaction, attractive life style, and challenging subject matter—integral components of psychiatry. Other studies have compared perspectives of students across different backgrounds (4, 5), changing attitudes over time (6, 7), change before and after clerkship (8), or effect of individual factors on choice of specialty (9–12).
Our study explored the attitudes of Pakistani medical students toward psychiatry as their future career. A comparison of our findings with similar studies from different regions and within different specialties would be interesting. We expected to learn whether certain factors like socioeconomic variables, financial rewards, prestige, and challenging subject matter are as important in our part of the world as they are in other settings. This could help us to assess the attitudes of future doctors toward psychiatry as a specialty compared to other specialties.
Students in their third year in four medical colleges across Pakistan were approached to participate in the survey. Aga Khan University Medical College and Karachi Medical and Dental College are located in Karachi, Sindh province; Punjab medical college is located in Faisalabad, Punjab province; and Ayub Medical College is located in Abbotabad, North West Frontier province. These four colleges are in the three largest provinces of Pakistan. Aga Khan Medical College supposedly caters to higher social strata while Karachi Medical and Dental College covers the middle and lower-middle classes of society. Punjab Medical College and Ayub Medical College are state-run colleges and provide services to the lower, lower-middle, and upper-middle classes of society. These three provinces have diverse cultures and they speak different languages, though the medium of medical education is English at all of the medical colleges. Thus, our study sample can be taken as fairly representative of Pakistani medical students. We selected third-year students because first- and second-year students carry mostly societal influences regarding psychiatry but have minimal contact with clinical subjects. Senior students may have developed biases regarding certain specialties thus influencing their opinions.
In Pakistan, third-year students go through general internal medicine and general surgery rotations, which bring some clinical perspective to their medical education. However, we do not know if the societal influence that they had carried to the medical school changes by the time they are in third year. In all but one medical college (Aga Khan University), teaching of behavioral sciences and psychiatry is restricted to the fourth year and beyond. At Aga Khan University (AKU) behavioral sciences are taught from the first year. A psychiatry rotation is part of the fourth-year clinical schedule in which the students spend 2–4 weeks in the inpatient unit as well as outpatient clinics. There is great variation in the quality of these rotations; in some places (e.g., AKU), there is a structured rotation with end-of-term exams while at other places it may not be more than an observership.
We used a questionnaire adapted from Feifel et al. (3) with prior permission from the authors via e-mail. This is a 24-item questionnaire requiring 15–20 minutes to complete; except a few open-ended questions, the majority of the items are in a 5-point Likert scale format. The items explored five areas: the demographic backgrounds of the students; which generic factors students considered important in their choice of a specialty; the degree to which students were considering possible careers among various medical specialties (family practice, internal medicine, pediatrics, surgery, obstetrics/gynecology, and psychiatry); the degree to which students found these specialties attractive as careers with regard to the various aspects listed in Table 2. For each applicable item in the questionnaire students were asked to provide a response for several specialties, including psychiatry. In our analysis, the questionnaire’s 1–5 rating scale was treated as a quantitative variable. A score of 1 meant very attractive and 5 meant extremely unattractive. Mean scores closer to 1 indicate high desirability of a particular specialty with respect to the aspect being rated. Likewise, a score closer to 5 indicates its lack of attractiveness. The Freidman test was applied to assess the significance of the difference in mean scores among groups. The Fiefel questionnaire does not have any reliability/validity data available. Students were blind to the specialty of the investigators and the specialty focus (psychiatry) of the study. Formal ethical review of this study was not sought because this was a voluntary, anonymous survey of students; however, a departmental ethical review committee at AKU approved the study.
The original version of the questionnaire was modified slightly to adjust for issues related to culture and the education system. The modifications were made after focus group discussion among principal investigators and senior medical students who were not part of the survey. For example, in the demographics section, race was replaced with mother tongue, and college major was replaced with premedical education. We did not translate the questionnaire because all medical colleges of Pakistan use English as the medium of instruction. Descriptive statistics including frequencies and cross-tabulations were generated. Chi-square tests were applied to assess the association of various responses to different variables. The Freidman test (13) was applied to measure the significance of the difference in scores among specialty choice groups.
A total of 381 out of 635 students in all four medical colleges filled out the questionnaire. The response rate was 60%; 57% of respondents were female, and almost all were Muslims (98.4%). The mean age of respondents was 21 years (SD=1.11). Table 1 summarizes the demographic characteristics of the participants as well as the class size of each of the four medical colleges.
No significant differences were found across the medical colleges between the students in age, gender, and premedical education. There was a significant difference in monthly household income. There was also a significant difference between genders for the reason to choose medicine as a career. More females cited personal interest (χ2=66.814, p=0.009) while males cited family pressure (χ2=4.87, p=0.027) as the reason for choosing their career path. More males considered careers other than medicine prior to entering medical school (χ2=11.718, p=0.001). For 7.6% of the respondents, psychiatry was the preferred career choice or highly likely choice. When this response was cross-tabulated with gender, premedical education, family income, and medical college, no statistically significant association was found. Table 2 compares the means of ratings of various aspects of training within different medical specialties.
Among those who rated psychiatry as their career choice, significantly more rated it very attractive or attractive in relation to lifestyle, interesting subject matter, intellectual challenge, rapid advances in understanding, having a bright future, and association with other psychiatrists. Significantly lower numbers of students who rated psychiatry as their first choice thought it to be financially very rewarding or attractive with respect to the degree to which this specialty draws upon all aspects of medical training.
Figure 1 shows a comparison of our study to U.S. and Israeli studies (3, 14) about the frequency of all responses related to choice of psychiatry as career. More people in our group rated psychiatry as a chosen career as compared to the United States but fewer as compared to Israel. A large number (>60%) of our respondents had a negative view of psychiatry.
Our response rate of 60% is comparable to other similar studies (3, 14). In spite of inclusion of medical colleges from different regions of Pakistan, we did not find a significant difference among the groups with respect to rating psychiatry as their first choice. Compared to other studies (2, 3, 9, 14), a smaller proportion of students identified psychiatry as their career choice. At 7.6% our findings are close to the U.S. figure of 7.7%, but far less then Australia (15.1%) and Israel (32.8%). This is not very encouraging. The situation becomes even bleaker when seen in the context of the already very low number of psychiatrists in Pakistan.
Perhaps Pakistani medical students in their early clinical years carry the biases toward psychiatry that exist in our society. They may also be reflecting the attitudes of their supervisors from medicine and surgery. However, our study was not designed to determine this. One assumption is that the societal influence may decrease as the students progress in their career. Exposure to a psychiatric clerkship could also influence attitudes positively or negatively. Assessment of their attitude at year three therefore may have important implications and could be a weakness of the study. Another concern is the lack of reliability and validity data for the questionnaire itself.
The average age of entry to medical colleges is lower in Pakistan than in North America. Many of the students choose the medical profession to fulfill the wishes of their parents. It is not known how much the maturity level of students and attitude of parents would affect students’ attitude toward psychiatry.
Similarly, increasing numbers of students are interested in studying abroad. This observation is based on discussions with our colleagues at different medical colleges. This could also affect their specialty choice, although, we are at present unable to determine this with any certainty.
How many of these students will settle abroad? What percentage will return after completion of their training? We do not know. We do know, however, that a significant proportion of medical students pursue psychiatry in developed countries such as the United States and the United Kingdom, and they later practice in those countries. In the United States alone there are about 10,000 Pakistani physicians training or practicing, and this number includes many psychiatrists (15).
As evidenced by comparison of mean scores (Table 2), psychiatry was rated neutrally or with some indifference toward the specialty. This may have resulted from a basic lack of awareness, lack of interest, or the relatively low prestige attached to the profession. This finding is similar to earlier studies.
Another relevant issue influencing the opinions of medical students could be the availability and quality of postgraduate training slots in Pakistan. At present, 17 institutions are recognized for training in psychiatry, having 100 trainees at levels 1–4. On average, only five trainees out of about 25 qualify each year in the exit level examination to practice as psychiatrists (16). The numbers of approved training posts are limited. Low passing rates and a shortage of approved training posts might discourage the interested candidates even further. Pakistan cannot even meet its needs for general health care given the current levels of production (17). The situation is worse for mental health.
A low number of locally trained and a tiny number of foreign trained psychiatrists leave the system with a dearth of role models for our students to look up to, thus maintaining a status quo in the areas of service and training. Unless we have a better understanding of the factors behind the attitude development of medical students about selection of specialty, we may not be able to come up with concrete suggestions to remediate this situation. Our study has highlighted lifestyle, interesting subject matter, intellectual challenge, rapid advances in understanding, having a bright future, and association with other psychiatrists to be contributing factors in determining psychiatry as a career choice. Therefore, skillful and enthusiastic presentation of a specialty during clerkship might improve attitudes toward psychiatry (3).
In the future it would be interesting to see any change in the attitudes of these students once they are exposed to psychiatry. We did not find a significant difference in the students of Aga Khan University where behavioral science is taught from the first year, and the other three medical colleges. It would be interesting to repeat this study later, as the other medical colleges are now planning to incorporate behavioral science in their preclinical curricula.
The authors acknowledge Mr. Muhammad Zaman, Research Officer, Department of Psychiatry, for his help with data collection and entry; Mr. Iqbal Azam, Assistant Professor, Community Health Science, for his help with data analysis; and Professor Murad Khan, Chairman, Department of Psychiatry, for his comments and help in reviewing the manuscript. All are based at Aga Khan University, Karachi.