Medical students' attitudes toward psychiatry have been a focus of study in the continuing effort to recruit trainees to the field. Several surveys of U.S. medical students have been published in the U.S. literature (1—9), and surveys of medical students in foreign medical schools have appeared in the international literature (10—14). However, only one study has been published in the United States concerning foreign medical students' attitudes toward psychiatry (15).
The proportion of psychiatry residents in the United States who are international medical graduates (IMGs) approaches one-half. In 1995—1996, the percentage of postgraduate year (PGY)-1 residents who are IMGs was 43.7%, and the percentage across all postgraduate years was 38.6% (16). The Indian subcontinent (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan) contributes one-third of U.S. IMGs in psychiatry residencies, yet there have been no studies published in the U.S. literature describing these countries' medical students' attitudes toward psychiatry. Further, it is notable that there are no studies from the African continent in either the U.S. or the available international literature. Availability of this information might be helpful to U.S. residency training directors in screening and selecting IMG applicants for their programs. This information may also be helpful during the national debates on physician recruitment.
Major problems discourage the assumption that IMG attitudinal data comparable to U.S. medical graduate data could be gathered from IMGs applying for residencies in the United States. The characteristics of the IMG applicant population are not known, since there is no central database. IMGs applying for U.S. residencies from their home countries prior to entering the United States would be very difficult to survey. IMG applicants have diverse prior professional experiences, ranging from none to postgraduate training to the practice of medicine abroad. The cultures in which IMGs have lived vary widely by geographic location, ethnicity, and religious background. Some IMGs in the United States are new arrivals, whereas others have spent many years in this country. All of these sources of IMGs' diversity may lead to a greater variation in attitudes compared with U.S. medical graduates, who are a more homogeneous group. For these reasons, surveying international medical students while they are in school in their native land is the method most comparable to those used in studying U.S. medical students.
We present the results of surveys conducted in India and Zimbabwe. Our choice of countries and medical schools was determined by the circumstance of opportunity and by our experience with these countries. We present this information to further acquaint training directors with national and cultural variations in medical students' education in, and attitudes toward, psychiatry. The demographics and characteristics of the medical students we surveyed are given in T1.
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Medical Education and Psychiatry
Western medical training in both countries originated during the British colonial period, and English continues to be the language of instruction. The usual course of a physician's education in India consists of 12 years of schooling beginning at about five, 5 years of medical school, and 1 year of mandatory internship. Some students take an optional 3-year baccalaureate in science or arts prior to medical school.
Indian psychiatry has a strong neuropsychiatric and descriptive/ phenomenological basis and includes the Hindu cultural emphasis on the person's integration into the family as a normal and health-restoring way of life. Undergraduate training in psychiatry usually takes place during a 4- to 6-week rotation during the fourth year. It consists of classroom lectures on various psychiatric syndromes and treatment modes. Supervised clinical training takes place concurrently in both inpatient and outpatient settings. This experience includes the International Classification of Diseases (ICD) and DSM diagnosis of major syndromes; psychiatric rehabilitation and treatment of substance abuse; and practical experience in interviewing and in various biological interventions, including electroconvulsive therapy (ECT). However, the scope and intensity of Indian medical students' experiences in psychiatry are not strictly uniform throughout the country, and the U.S. training director should examine each applicant's background thoroughly.
Zimbabwe's only medical school is located in the capital city of Harare. During the Rhodesian colonial period, the medical school was affiliated with the University of Birmingham in the United Kingdom. Since independence in 1980, the medical school has been a component of the University of Zimbabwe. Thirteen years of education beginning at age six are required before enrollment in medical school. The course of medical studies lasts 5 years. Enrollment is about 75% Shona and 25% Ndebele (Zimbabwe's two major indigenous groups).
The department of psychiatry teaches a second-year behavioral science course, a third-year psychopathology course, and a fourth-year 6-week clinical clerkship. The behavioral science course includes study of traditional African medical practices, the biology of behavior, human growth and development, and human sexuality. Psychopathology is phenomenological-descriptive, using ICD classifications, and the clerkship is preponderantly on inpatient services.
We selected items from the attitude survey devised by Nielsen and Eaton (2). These questions, listed in T2 and T3, had been used previously in other international studies (10,13,14). In addition, we formulated several questions about attitudes toward toward the United States based on opinions commonly expressed by IMG applicants in the United States (T4.) We also asked about the students' thoughts or plans regarding postgraduate emigration to the United States or to other countries. The questionnaire was in English, the language of instruction in both countries.
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Sample and Survey Administration
The medical schools in the present example are located in the southern Indian city of Bangalore in the state of Karnataka. Bangalore is a large multilingual, multireligious, and multiethnic city that draws students primarily from Karnataka and from many other regions of the country. The language of Karnataka is Kannada, and the two common languages of India, English and Hindi, are widely spoken as well. The major religion is Hinduism, with substantial numbers of Muslims and Christians. Bangalore is home to several international technological industries as well as India's National Institute of Mental Health and Neurosciences.
The three schools surveyed are examples of the three major types of medical schools in India: state schools, in which admission is based on performance on an entrance examination (similar to the MCAT) with preference given to state residents; missionary schools, in which admission is based on religious affiliation as well as examination performance; and private colleges, in which admission is based on the student's ability to pay and examination performance.
Each school provides only one example of the three medical school types, located in the capital city of only one of the many culturally, economically, and politically diverse states of India. As such, the examples cannot be considered statistically representative of the three types of schools, the proportion of all Indian medical students in each type of school, nor of medical students in that nation as a whole. There is no central database in India with which our examples' characteristics can be compared.
We conducted the survey among the fourth-year medical students at the three medical schools. In this year, students have courses on social and preventive medicine, ophthalmology, and ear-nose-throat surgery. They also have a 6-week rotation in psychiatry at some time during the year. More than 80% of the students in this example had completed their psychiatry rotation at the time of the survey. These data were not available by individual, but only on an aggregate basis. Thus, a limitation of this study is that we were not able to analyze the dependent variables by psychiatry rotation completion.
The questionnaire was administered during a lecture class. Anonymity was guaranteed. All students attending the lectures returned the forms, yielding a sample of 67% of fourth-year students enrolled at the three schools.
Harare is major trade and manufacturing center with a regional population of nearly a million. The presence of more than 100 foreign embassies, expatriate instructors at the university, and several aid agencies contribute to the international atmosphere.
The surveys were distributed to fourth-year students at the end of a lecture on Freudian theory given by one of us (IC), a part of the core lecture series required for the psychiatry clerkship. Anonymity was guaranteed. All 46 students attending the lecture returned a completed form, yielding a sample of 58% of the fourth-year medical students. The students had completed a majority of their psychiatry clerkship by the time the survey was given, but individual data on the proportion of the clerkship that each respondent had completed were not available. As with the Indian students, we were not able to analyze the dependent variables by the proportion of the psychiatry clerkship completed.
Between-group demographic differences were analyzed using χ2 exact tests, t-tests, and one-way ANOVAs.
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The Three Indian Medical Schools
The schools differed significantly on four demographic characteristics: age, education between high school and medical school, self-described social class, and the state in India in which they were born. There were four significant differences among the medical schools on the 54 dependent variables relating to attitudes toward psychiatry, sources of influence on these attitudes, attitudes toward the United States., and intentions for postgraduate study and for emigration. These four significant differences represent 7% of the 54 items, little more than the 5% that would be expected by chance when conducting 54 statistical tests. Thus, while there are interpretable demographic differences among the three schools, the schools as a variable have virtually no impact on the dependent variables. We therefore pooled the data for the three schools, still with the caution that we have no way of ensuring that they are statistically representative of all Indian medical schools of their type.
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Indian Schools Compared With the Zimbabwe School
While the survey was distributed to the two groups during the next to last year of their training, there were many significant differences among the characteristics of the two national groups. Compared with the Zimbabwe students, the Indian students were younger, more frequently female, and less likely to be married. The Zimbabwe students were much more likely to identify themselves as poor and less likely to have had formal education between high school and medical school. Over half of the Zimbabwe students indicated they were incurring debt, compared with 3% of the Indian students.
Because of these differences, differences in the sampling methods, and lack of assurance of national representativeness of the Indian examples, it is not appropriate to statistically compare the two groups with each other or with American samples. The Indian examples, collectively, and the Zimbabwe example are discussed together, for this provides an economy of presentation. No test of statistical significance is implied.
The most popular first-choice careers were internal medicine (25%), pediatrics (24%), and surgery (21%). Fourteen percent rated psychiatry as one of their top three choices, 3% indicating it as their first choice.
The most popular first-choice careers were obstetrics/gynecology (26%), pediatrics and surgery (21% each), and internal medicine (14%). Twenty-four percent listed psychiatry as one of the top three choices (primarily third); 2% ranked psychiatry as their first choice.
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Attitudes Toward Psychiatry
Both groups of international students indicated neutral to favorable attitudes toward psychiatry. They registered solid opinions that psychiatry is not a waste of medical education, that talk therapy is helpful, and that they would recommend a psychiatric consultation for a family member if needed. Both recognized advances in the biological therapies for schizophrenia. Both groups gave some endorsement to the greater effectiveness of psychiatrists over local healers, and both tended to have some reservations about family reactions to a career in psychiatry. ECT is practiced in India but not Zimbabwe, accounting for the differences observed on that question.
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Experiences That Influenced Attitudes Toward Psychiatry
Both student examples indicated that their clinical and academic experiences related to psychiatry, as well as own personal and their family's experiences, somewhat increased their interest in and respect for psychiatry.
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Attitudes Toward Aspects of U.S. Culture and Medical Practice
Both groups tended to agree with negative statements about the United States. Only the Indian students responded favorably to the shared responsibility among MDs and other health care professionals that is found in the United States. Both groups tended to agree that there are greater opportunities for a physician to make money in the United States.
When asked whether they had thought of emigrating to the United States, 44% of Indian students replied they had not, 34% had thought about it but had no plans, and 22% stated they had plans to emigrate. Among the Zimbabwe students, the numbers were 76%, 22%, and 2%, respectively.
Our study of a selected sample of Indian medical students and Zimbabwe medical students found that psychiatry was the choice of only 2%—3% of the students, and internal medicine, pediatrics, surgery, and obstetrics/gynecology were the preferred specialties. Nonetheless, both groups of students indicated neutral to favorable attitudes toward toward psychiatry. Twenty-two percent of Indian students and only 2% of Zimbabwe students indicated that they had plans to emigrate to the United States, and an additional 34% of Indian students and 22% of Zimbabwe students stated that they had thought about emigrating to the United States. The Indian medical students' emigration plans were held despite negative attitudes toward some aspects of U.S. life: the prevalence of violence, women's sexual liberation and assertiveness, and poor care of the elderly. Finally, a substantial number of Indian students (98%) considered themselves to be middle or upper class, whereas 44% of the Zimbabwe students described themselves as lower class.
The students' choice of specialty may be seen in the context of the cultural and economic environment in which they plan to seek postgraduate training and to pursue a career. Indian medical schools graduate about 15,000 physicians each year, similar to the number of U.S. graduates. However, compared with the United States' roughly 1,100 PGY-1 psychiatry positions, India has only about 120 first-year psychiatry positions. India's emphasis on training in primary care and the shortage of postgraduate psychiatry positions available (17) would not encourage many graduates to plan on psychiatry. The situation in Zimbabwe is closer to that in the United States: the number of postgraduate training positions in psychiatry is adequate for the number of interested medical school graduates. Thus, Zimbabwe medical students have ample opportunities open to them in Zimbabwe and few educational or career incentives to look elsewhere for psychiatric training.
The percentage of medical students selecting psychiatry for postgraduate study in this survey is within the range found in various international studies. In 1993—1994 (the period of these surveys), 3.1% of U.S. medical graduates matched U.S. residency programs in psychiatry (18). An earlier paper reports that 4% of graduating medical students in Britain chose psychiatry as a career, and in Hong Kong 2%—3% of graduating medical students chose psychiatry (13). While there are no national data available for India and Zimbabwe, the similarity in the percentages of graduating medical students in our study who chose psychiatry under various educational systems, opportunities for practice, and national priorities, to that of the United States, Britain, and Hong Kong, is remarkable and deserves a thorough examination.
Even though a small percentage of students considered postgraduate education in psychiatry, both groups of students indicated neutral to favorable attitudes toward psychiatry. The finding of a positive skew of the Indian students' attitudes toward psychiatry is consistent with Alexander and Kumaraswamy's study, using a similar set of Nielsen and Eaton items, of 146 final-year students at Kasturba Medical College in Manipal, India (14).
The students' perceptions of the United States, often gained through distorted media representations, conflict with their own traditional values about family, gender roles, and the position of the elderly (19). However, they do see the United States as a society open to greater opportunities for physicians, and, indeed, the United States does compare quite favorably, for example, to the United Kingdom and Canada, which have much more rigid restrictions regarding foreign physicians.
The motivations of the 22% of Indian medical students who have planned emigration to the United States may be similar to other IMGs in the United States. The authors of an earlier study (20) observed that there were three major motivating factors for IMGs to emigrate to the United States: to seek specialty training, to make more money, and to obtain employment opportunities less available in their home countries. This observation regarding an earlier generation of IMGs may also be applicable to the Indian students who had plans to emigrate to the United States. Indian students have a long tradition of going abroad to study, and India has few postgraduate training and career positions in psychiatry for those who are interested. The students' self-described middle and upper social-class status may provide them with the financial means to emigrate. Finally, they recognize that they will find jobs and be able to earn a greater income in the United States.
Zimbabwe students have little need to leave their home country to pursue training and a career in psychiatry, have no established pattern of emigrating to other countries to pursue careers, and, being predominantly lower and middle class, have fewer financial resources to afford emigration if they wished to do so.
Even if the true proportion of the Indian medical student population who plan to emigrate to the United States is only a fraction of the 22% found in our study, there will be a large pool of physicians wanting to enter the United States. It has been pointed out that, despite the obstacles to their entrance, the number of IMGs has grown in the past decade and the factors that have affected the U.S. physician workforce will continue to necessitate IMGs' inclusion in workforce projections (21).
Our conclusions regarding the data and their implications are limited by the design and conduct of this study. Although we did have an example of each of the three types of Indian medical schools, we have no way of knowing whether they are representative of their type nationally. They are located in only one of many geographically and culturally diverse Indian cities and states. As a consequence of this lack of a random sampling method, contrasts between cohorts could not be statistically tested. Though we estimate that the majority of the students in both countries had completed their psychiatric rotations, we were unable to sufficiently determine the degree of their exposure to psychiatry to enable us to study this variable. Also, though the anonymity of the students' responses was guaranteed, the presence of the Indian—American psychiatrist—guest in the Indian classrooms may have produced a bias toward responses favorable toward psychiatry and the United States. A similar possible bias toward psychiatry may have occurred in the Zimbabwe classroom.
We have described, for two national examples of medical students, their attitudes toward psychiatry, the degree of influence that various sources had on these attitudes, their attitudes toward certain aspects of U.S. culture, and their postgraduate specialization and emigration plans. We note the large proportion of Indian students who plan to emigrate to the United States. Of those who were not planning U.S. emigration, many had thought about it and, we might assume, could think about it again. While their attitudes toward psychiatry may be positive, they are likely not to have had as much exposure to the field as U.S. medical graduates, and training and career prospects in psychiatry in India are not favorable. Thus, they may not have demonstrated a long-term primary interest in psychiatry. Applicants who come to the United States with a new menu of opportunities may have their first real chance to choose psychiatry as a career.