The number of U.S. medical graduates going into psychiatry following World War II was 10% with a subsequent decline to 5%–6% by the 1990s (1); by 1998 only 2.9% of American medical graduates were selecting psychiatry as a career (2). However, the number of residents in general psychiatry and child and adolescent psychiatry training programs remained fairly stable in the 1990s because of the increase in the recruitment of international medical graduates, which now approximates 50% (3). The number of American medical graduates going into psychiatry increased slightly (3.9%) in 2002 (4). This improvement was thought to be related to students’ increasing concern with life style, better salaries, and the evolving interest in neurobiology (4).

The U.S. Surgeon General’s Report (5) stated that one in five children has a diagnosable mental disorder, and 5%–9% will have a mental disorder, which significantly impairs their capacity to meet the ordinary demands of everyday life. The U.S. population is expected to increase to 336 million by the year 2020 and to 420 million in 2050. The population of children and adolescents under age 18 is projected to grow by more that 40% in the next 50 years from the current 70 million to more than 100 million by 2050 (U.S. Bureau of the Census, 2000). Approximately 26% of the population will be less than 19 years old. The 2002 Institute of Medicine report (6) has stressed the need for a more ethnically diverse spectrum of providers as international migration and immigration will play a much larger role in the surge of Asian-American and Latino populations. By the year 2050, Hispanics will double and make up 24.4% of the population, while the white non-Latino population will increase only 7%.

Many communities report a lack of child psychiatrists and inpatient crisis beds for children (7). Thomas and Holzer (8) calculated that the United States has only one child psychiatrist for every 2,238 children with a diagnosable mental disorder and 1.6 child psychiatrists for every 1,000 children with a severe mental disorder. Untreated childhood disorders are subsequently associated with school failure, poor employment opportunities, suicidal behavior, early death, and contact with the juvenile justice system (9, 10). Sixty-six percent of boys and almost 75% of girls in juvenile detention have a mental disorder (10).

Interest in expanding the child and adolescent psychiatry workforce is increasing (3, 5). The Council on Graduate Medical Education has consistently noted the dramatic need for more child and adolescent psychiatrists and suggested that 30,000 would be needed (3). This goal is currently unobtainable, but clearly suggests increasing public awareness of the mental health needs of youth in the United States (3). Reports from the U.S. Department of Public Health and Human Services, the Council of Graduate Medical Education, and the Institute of Medicine have stressed the need for more child psychiatrists. Currently, approximately 7,000 child and adolescent psychiatrists are practicing in the United States (11). The U.S. Bureau of Health Professions has estimated that by 2020 we will need 12,624 child and adolescent psychiatrists to meet the projected demands. At current recruitment levels, the nation will have only two-thirds (8,312) of the child and adolescent psychiatrists needed to meet those demands. In spite of the apparent need for more child psychiatrists, the number of training programs in child and adolescent psychiatry decreased from 130 in 1980 to 114 in 2005, and these programs graduate approximately 300 trainees per year (11).

Given the clear training opportunities in child and adolescent psychiatry, we need to further explore the barriers that interfere with medical students and general psychiatry residents in considering more seriously child and adolescent psychiatry as a professional career.

Participants

Medical students (n=154) and general and child and adolescent psychiatry residents (n=111) took part in the study. The medical schools at University of Alabama-Birmingham (n=100), the University of Miami (n=93), Emory University (n=51), and the Medical College of Georgia (n=21) participated for a total of 265 participants. Subjects were asked to anonymously complete a questionnaire and had the option to refuse to participate. This study was approved by the human subjects review board at each institution.

Questionnaire

The questionnaire was divided into several sections: sociodemographic items, experiences related to child psychiatry, professional career preferences, personality attributes, social interests, and perceived life style elements of importance. Sociodemographic items included gender, ethnicity, citizenship and marital status, medical school attended, and educational indebtedness. Child psychiatry experiences included questions about seminars, inpatient, outpatient, consultation-liaison, clinical rotations, psychotherapy, psychopharmacology, crisis, substance abuse, mentorship, and time spent with faculty. Professional career preferences included ranked interests in pediatrics, internal medicine, family medicine, and neurology and their ranked areas of interest, such as research, teaching, school consultation, independent practice, clinical practice at an inpatient or outpatient facility, and administration. Personality attributes consisted of being socially related, logical, assertive, genuine, empathic, having an expressive personality, warmth, self-directedness, cognitive flexibility, tolerance for ambiguity, perfectionism, being introverted, and being extroverted. Social interest statements included cooking, shopping, surfing the Internet, playing video games, reading, enjoying sports, outdoor activities, theater, indoor activities, TV/movies, music, and arts/crafts. The importance of life style elements were job opportunities, earning potential, quality of life, intellectual interests, stress, status among faculty/house staff, status in society, social systems approach, satisfaction working with psychiatric patients, developmental perspectives, and opportunities for research.

Data Analysis

Data were analyzed using SPSS 15.0 (2005, Chicago). Frequency and descriptive statistics were calculated to check all relevant characteristics of the data. As all items of interest were categorical, comparisons were tested with chi square. Comparisons were first made between general psychiatry residents and child and adolescent psychiatry residents. No significant differences between the two groups of residents were found, so all residents were collapsed into one group for analysis purposes. Thus, all psychiatric residents were compared to medical students on common questionnaire items.

The proportion of men and women represented in the psychiatric residents and medical students was comparable, but we found different percentages for ethnicity, citizenship, marital status, and location of medical school attendance by trainee type (Table 1). While 78% of medical students were white, 62% of psychiatric residents represented various minorities, with Asians representing the largest subgroup at 28% (p<0.001). As expected, 98% of medical students were U.S. citizens, compared to 87% of psychiatric residents (p=0.001). Sixty-five percent of medical students were single, while 65% of psychiatric residents were married (p<0.001).

Personality Attributes

Psychiatric residents were compared to medical students on self-report items of personality attributes. Psychiatric residents reported being “more” or “very much more” socially related (p=0.006), empathic (p<0.001), extroverted (p=0.025), warm (p=0.003), and to have greater tolerance for ambiguity (p<0.001), when compared to the medical students. None of the other attributes was significantly different between the two groups. See Figure 1 for a distribution of the scores on all attributes.

Importance of Life Style

Psychiatric residents were more likely to stress as important mediators in their career selection such features as quality of life (p=0.029), a social systems approach (p=0.009), the developmental perspective (p<0.001), and a greater satisfaction working with psychiatric patients (p<0.001).

Social Interests

Psychiatric residents were less likely to demonstrate significant interests in sports (p=0.013) and outdoor activities (p=0.042) compared to the medical students.

Career Choice Interest in Psychiatry

Twenty-eight percent of medical students (n=43) indicated a strong interest in psychiatry as a career choice (Figure 2). Separating medical students into white students versus all others (given that white students make up 78% of the sample) did not reveal any differences among career choice interests in contrast to the overall findings. Only 22% of medical students (n=34) (23% of white students, n=28, and 19% of all others, n=6) indicated they would not consider psychiatry as a career opportunity (Figure 3).

Career Choice Interest in Child Psychiatry

Sixty-four percent of general psychiatry residents (n=44) upon entering training in general psychiatry considered child psychiatry as a career choice. Fifty-three percent of general psychiatry residents (n=36) expressed an interest in child psychiatry as a career at the time of the survey. Forty-two percent of general psychiatry residents (n=29) indicated they were “very much” interested in the possibility of child psychiatry as a career choice. Reasons given for not choosing child and adolescent psychiatry training by the general psychiatry residents were indebtedness (3%, n=2); too many years of training (13%, n=8); did not like child psychiatry rotation (19%, n=13); and preferring to work with adults (33%, n=22) (Figure 4), and these percentages were consistent when comparing whites versus all others.

Child Psychiatry Experiences

Child and adolescent psychiatry residents gave as major motivations for choosing child psychiatry the following interests: a desire to teach (16.3%, n=7); independent practice (18.6%, n=8); an interest in child and adolescent inpatient clinical practice (7.0%, n=3); outpatient work (20.9%, n=9); administration (2.3%, n=1); and 7.0% (n=3) were considering another fellowship, such as forensic or addiction subspecialty training.

Child psychiatry residents were asked to rate their experiences during their training from “not important” to “very important.” The following experiences were rated as “more” or “very important” in increasing order of importance: adolescent substance abuse (39.5%, n=17); crisis (40.5%, n=18); seminars in growth and development (48.7%, n=21); consultation-liaison experience with children/adolescents (53.6%, n=23); seminars in developmental psychopathology (56.1%, n=24); psychopharmacology with children/adolescents (61.0%, n=26); psychotherapy supervision with children/adolescents (65.8%, n=28); inpatient clinical experience with children/adolescents (67.5%, n=29); supervision/mentorship with children/adolescents (73.2%, n=31); working with families (73.8%, n=32); child psychiatry faculty (87.5%, n=38); outpatient clinical experience with children/adolescents (80.5%, n=35); and child and adolescent clinical experience (95.1%, n=41).

The President’s New Freedom Commission on Mental Health (10) recognized that mental illness ranks first among illnesses that cause disability in the United States and highlighted “the extent of unmet mental health needs,” the stigma of mental illness, and the barriers that impede access to mental health care. Concomitant with this recognition is an increasing focus on being able to attract the “brightest and best” to careers in mental health; specifically mental health professionals who are interested in children and adolescents with mental disorders. Our study, as noted in Table 1, indicates the increasing diversity of the ethnicity and race of students going into general and child and adolescent psychiatry. We, however, need to attract more diverse students that would resonate with all of the various minorities in the general population, not only along ethnic/racial differences, but also with other minorities, such as gay, lesbian, bisexual, and transgendered youth.

Medical students have generally been described as being relatively uninterested in psychiatry and that only about half endorse general psychiatry as a “respected area of medicine” (12). However, in our survey we found a surprising number of medical students (78%) who considered psychiatry as a possible medical specialty and 28% expressed a strong interest in psychiatry. Cutler et al. (13) found in their study of medical students who seriously considered psychiatry as a career choice that most were attracted to the intellectual challenges, the quality of life, and they were more likely to experience greater satisfaction in working with psychiatric patients. The authors noted several factors that have a negative impact on medical students choosing psychiatry as a career (i.e., the perceived professional status of psychiatry, poor earning potential, and the impact of the current health care system changes on psychiatry). Martin et al. (12) noted that medical students have a more favorable impression of child psychiatry than general psychiatry residents as a respected area of medicine.

Whereas another recent study (14) found that only 30% of general psychiatry residents entering training express an interest in child and adolescent psychiatry, our findings suggest that general psychiatry residents may now be more interested in child psychiatry as a career. We found that 64% of general psychiatry residents have seriously considered child psychiatry as a career choice. This seems to be reflected in the increasing awareness of job opportunities and the growth of earning potential as a child psychiatrist.

Our study also addresses barriers to recruitment into child and adolescent psychiatry. While it is usually thought that financial considerations are paramount, we found this not to be a decision breaker. Only 3% of general psychiatry residents listed indebtedness as a factor in not choosing child psychiatry. Surprisingly, 19% did not like their child and adolescent psychiatry rotation. The reasons given often reflected the limited exposure to the diversity of child and adolescent psychiatry practice. A number of general psychiatry residents interviewed in a discussion group indicated they were “turned off” by being predominantly exposed to seriously disturbed children with a high preponderance of externalizing symptoms emphasizing medication management only. Often when it is stated that they chose not to go into child psychiatry because of a preference for working with adults it was because they assume that child psychiatrists only treat children.

Not surprisingly, child and adolescent psychiatrists rated as most important in their training those experiences associated with clinical practice and the quality of the teaching faculty. Of particular interest is the perceived importance of psychotherapy supervision at a time when this form of training has been gradually deemphasized as a part of the curriculum.

Several ideas have been suggested to facilitate recruiting medical students into psychiatry, and subsequently child psychiatry, including increasing the exposure to child mental health in existing medical school curricula; providing travel grants for medical students to attend child and adolescent psychiatry national conferences; expanding federal provisions for “loan forgiveness” for medical students in child mental health; improving the opportunity for “triple board programs”; offering research training tracks in child psychiatry, such as in the Yale Child Study Center; and giving more attention to medical school admission committee selection criteria, which may tilt away from those with a stronger interest in the humanities (2, 5, 11). Others have noted the importance of having medical students with an interest in psychiatry to form groups with ongoing exposure to the many exciting dimensions of psychiatry through speakers, clinical discussions, and films. Additional efforts, such as the “Post Pediatric Portal Project,” have focused on attracting pediatricians into child psychiatry (11).

The cross-sectional nature of this study limits the overall findings and implications. Additional studies that follow medical students through the course of their medical school training to determine how exposure to different curricula influences their professional interests are necessary. Adding longitudinal assessments that inquire about specific experiences relevant to psychiatry might also shed additional insights into the career choices that medical students make. Selecting medical schools beyond the Southeast region for participation in subsequent studies would also help to generalize the findings on a national level. Thus, additional studies are clearly necessary to further explore the rather precipitous drop in interest in psychiatry as a career for medical students and the loss of interest of general psychiatry residents in choosing child psychiatry as a career.

The mental health needs of our youth indicate not only the requirement to develop a multifaceted “systems of care” approach with attention to private and public health insurance, Medicaid budgets, and culturally/ethnically sensitive outreach program to minority populations, but also an awareness of the need to recruit professionals who can provide such care. As a profession, we need to reach out to stimulate and validate the latent interest of medical students in psychiatry and to promote and educate general psychiatry residents as to the rich and diverse professional opportunities in a child and adolescent psychiatry career.

At the time of submission, the authors reported no competing interests.