(Quoted by Cicero: “To whose benefit, advantage?”)
Recruitment is recognized as a key measure of the standing of the profession and, in medicine, the value of a specialty field. It is not a perfect measure—the absolute number of individuals who enter highly competitive fields such as neurosurgery, dermatology, and orthopedic surgery is small—and yet recruitment persists as an indication of “worth” in medical training. In psychiatry, a medical school program that consistently “delivers” more than a handful of students into psychiatric residencies at graduation is noticed and respected. Indeed, recruitment into psychiatry is seen as reflecting favorably on the field of psychiatry, the training environment of a particular department of psychiatry, and, accordingly, on the work of a medical student education director.
Some might argue, in fact, that psychiatry is a discipline especially concerned with recruitment. The reasons for this relate to the public health burden of mental illness and the personal suffering linked with mental illness across all ages, societies, and cultures as well as the insufficient representation of psychiatrists in the physician workforce throughout the world (1). Concerns about recruitment in our field also pertain to the relatively low number of American medical graduates applying to psychiatry and/or their perceived quality compared with applicants to other disciplines. Indeed, beginning in the 1970s, the number of medical students choosing psychiatric residencies started to decline (2). Later, during 1988–1998, the number of applicants into psychiatry dropped by 42.5% (3). According to the National Residency Match Program (NMRP) data from 2007 (4), applicants for psychiatric residency positions have one of the lowest average USMLE Step I scores, and the lowest scores on Step II, when compared with other specialties.
Brockington and Mumford (2) discuss various factors that may impact recruitment into psychiatry. Some students find the field to be “slow moving,” with treatment aimed at management rather than cure. These perspectives may change as educators integrate more evidence regarding the positive health care outcomes of psychiatric interventions into medical school curricula and as innovative applications of genetics (e.g., pharmacogenomics) are introduced into clinical practice and training. Students may also be negatively influenced by the low status of the profession, as evidenced by decreased relative salaries, stigma, and lack of respect from other physicians, family, and friends. Although a high-quality educational experience during medical school may improve students’ attitudes toward psychiatry, it is unclear whether or not recruitment is positively affected (5). Sierles (6) mentions the important role of the director of medical student education, stating “two of the three best predictors of career choice in psychiatry were the academic rank of the director and whether he or she had won an award in teaching.”
In light of this set of issues, directors of medical student education may feel that the responsibility for recruitment is a daunting task. Is it the director’s role to recruit medical students into the field, or is providing a quality educational experience to all medical students his or her primary charge? The Association of Directors of Medical Student Education in Psychiatry (ADMSEP) recently released a position statement related to this matter (7). The organization writes that the primary responsibility of its members is “to teach principles of good psychiatric care to all future physicians” regardless of specialty choice. Although ADMSEP recognizes the importance of quality teaching in attracting medical students to the field, it states that it is a “responsibility shared by all faculty members of departments of psychiatry.” Some directors may worry that they will be held responsible, or worse, blamed for the low number of medical students applying to psychiatry and/or to their department’s residency training program in psychiatry.
The director of medical student education is usually the most visible member of the department of psychiatry. The director often coordinates the basic science curriculum related to behavioral health, administrates the psychiatry clerkship, and is responsible for medical student grades. Balon and Riba (8) studied characteristics of directors of medical student education in psychiatry. Most are either assistant or associate professors and dedicated to their roles, with a mean length of tenure of 5.3 years. Sierles and Magrane (9) support evidence of this dedication in clerkship directors, 65.4% of whom report a career aspiration of staying in their current position. Compared with clinical work and research, most of the work week of both clerkship directors and directors of medical student education is spent teaching (8, 9).
Because the directors of medical student education are a visible entity at the medical school, recruitment seems like their natural role. The director of medical student education is at the “frontline” of presenting the specialty in a favorable light. He or she may influence students toward the specialty by selling those aspects students have stated are attractive about the field: the more relaxed life style, the humanistic approach to patients, and the ability to spend time with and truly get to know those whom one treats. On the other hand, should an educator be a salesperson for a product? Is there a role conflict and thus potential conflicts of interest when one’s primary mission is to teach the core principles of the specialty?
Medical student education directors thus experience very real ethical tensions in their work by virtue of their roles, which have closely but not perfectly aligned professional responsibilities. Honoring the task of preparing all medical students to become capable, sensitive, and diversely skilled physicians of the future means that medical student education directors must give most of their efforts to supporting the learning of the large numbers of students who will not become psychiatrists rather than the very few who will. The aspiration of a director to bring more early career professionals into the workforce to care for people living with mental illness—or more personally, the desire to “look good” to others by being an effective recruiter—can be at odds with the responsibility to fulfill teaching responsibilities to the 96% of medical students who will choose other fields of medicine.
Analyzing this set of issues utilizing basic ethical principles is helpful in establishing a moral groundwork for approaching the dilemmas surrounding recruitment and fulfilling our fiduciary responsibilities as ethical educators. The first principle, respect for persons, suggests that we should honor the fundamental values, gifts, and strengths of our students, helping them to identify the field that most fulfills their aspirations as individuals. Closely linked is the ethical principle of autonomy, which posits that individuals should make authentic choices that are free of undue outside influence. Applying this principle, medical students should interact with faculty as a means for learning clinical skills, not as an opportunity for recruitment to occur. The third core ethical principle, non-malfeasance, is commonly referred to as “first do no harm.” Is it harmful to persuade a medical student toward a certain specialty? Should not medical students be allowed to make this important decision based on their abilities and strengths as individuals, as suggested earlier? Fourth, according to the principle of beneficence, directors of medical student education must place primacy on the students’ well-being and heed the students’ interest, even to the neglect of theirs (and their department’s). This principle also brings out the issue of the benefits of society versus the benefits of the department and medical school. Finally, the principle of justice refers, among others, to an equitable distribution of resources to those in greatest need. Because most medical students we educate choose a career other than psychiatry, it makes sense that the greatest well-being and need, both for students and the psychiatric patient population, can be achieved by focusing efforts on teaching rather than recruitment.
An additional issue that evolves when examining the role of the director of medical student education in recruitment relates to promise-keeping and perhaps to professional loyalty as well. As Balon and Riba (8) note, at times funding for the position as medical student education director comes from various sources, not only departmental monies. If the director is paid solely by the department of psychiatry, is it feasible to assume that recruitment into the specialty should become a higher priority than other obligations? If the medical school is partly or primarily responsible for the funding, does broader education receive greater commitment or higher regard? More radically, should revenues determine the focus of one’s work as a professional?
By being asked to participate in recruitment into psychiatry, the directors of medical student education are exposed to double, if not multiple, loyalties and demands, and they are asked to participate in an activity that for them seems ethically challenged at best. It seems that from the ethics point of view, the recruitment should be left to the leadership of the residency training program (and other faculty), and the directors of medical student education in psychiatry should be left “to teach principles of good psychiatric care to all future physicians.”
“Quem dii oderunt, paedagogum fecerunt.”
(Old Latin proverb: “Whom the Gods hate, they make them teachers.”)
Disclosures of Academic Psychiatry editors are published in each January issue. At the time of submission, Dr. Morreale disclosed no competing interests.