Medical student education in psychiatry faces many challenges. Educators must balance the need to stimulate interest in psychiatry to improve recruitment versus the responsibility to provide adequate training in psychiatry for the approximately 95% of students who will choose other medical specialties.
This balance must be achieved against a perceived background of diminishing resources for psychiatric medical student education. Although definitive data does not yet exist, psychiatric educators across the country have observed diminishing contact time by faculty with medical students due to demands for increased clinical revenues. The perception also exists that funding for medical student education-related roles and positions within departments of psychiatry is steadily decreasing. Shrinking infrastructure resources for medical student education is widespread. Many psychiatry departments now have fewer clinical sites that can accommodate medical students. In order to address the perceived lack of resources for psychiatric medical student education, the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) is currently conducting a survey of its members to assess the adequacy of resources for psychiatric education (1).
Competition from other departments for curriculum time has also threatened the quality of our medical student education programs. While most psychiatry clerkships remain 6 weeks in length, the number of 8-week psychiatry clerkships is steadily declining (2). At many schools psychiatry rotations are being decreased to 4 weeks. Decreased curriculum time not only negatively impacts the acquisition of psychiatric knowledge but also interferes with students’ ability to understand the importance of psychiatry as an essential medical specialty.
Considerable interest has arisen within the past several years to reintegrate psychiatry, neurology, and other areas of clinical neuroscience. Much of this work has focused on expanding research training in psychiatry residency programs (3). A component of this endeavor, however, is examining the appropriateness of merging portions of the medical student curriculum in psychiatry with other neuroscience disciplines. This was a topic of intense discussion at the recent Education Summit cosponsored by American Psychiatric Association (APA) and ADMSEP. While any aspect of this discussion have merit, these changes may drastically alter the way in which psychiatry is taught in medical school.
Another challenge confronted by psychiatric educators is the view that students have of our specialty and our patients. It is likely that most students enter medical school with limited knowledge and understanding of psychiatry and psychiatric disorders. The stigma of mental illness is well-documented in our society. Negative student perceptions, coupled with the other factors outlined above, make it difficult for psychiatric educators to effectively train future physicians to recognize and treat psychiatric disorders. All of these issues also make recruitment more difficult.
This issue of Academic Psychiatry contains two important articles describing medical students’ perceptions of general psychiatry, child psychiatry, and psychiatric illness and how those attitudes may impact upon career choice. These articles will be briefly reviewed, followed by a discussion of how psychiatric educators might address the challenges we face.
In their article in this issue of Academic Psychiatry, Galka and associates discuss medical students’ attitudes toward psychiatry and mental disorders before and after a psychiatric rotation (4). The authors conducted pre- and postclerkship surveys of 672 medical students from 1997 through 2001.
This article contains a number of interesting and important findings. First, students have a greater understanding of both the biological and social causes of mental illness following the psychiatry clerkship. Appreciation of the effectiveness of psychotropic medication and psychotherapy is also increased. The psychiatry clerkship also appears to improve student perceptions of mental illness in general.
Two findings in the study should cause concern among psychiatric educators. Students generally viewed the treatment of patients with substance use disorders as ineffective. The clerkship also failed to increase student interest in careers in psychiatry.
What might explain the results found in this study? It is clear that an intense exposure to psychiatric illnesses during the clerkship will increase student understanding of the origins of these disorders. Likewise, direct experience with the various treatment modalities used by psychiatry improves appreciation of their effectiveness. In spite of these positive outcomes, it appears that our efforts to educate students about the importance of substance use disorders, and their comorbidity with other psychiatric conditions, is inadequate to overcome students’ negative views of these conditions.
While the psychiatry clerkship was viewed in a positive way overall, the lack of career interest in psychiatry following the clerkship is perplexing. Multiple factors influence student career choices. These factors have been well documented in the literature (5, 6). It is likely that many students have already decided upon a career choice before entering the psychiatry clerkship. This may be particularly true for students doing psychiatry clerkships toward the end of the third year. The clerkship, by itself, may not be enough to generate career interest in psychiatry no matter how positively students view it.
Another article of interest in this issue of Academic Psychiatry examines medical students’ perceptions of psychiatry and child psychiatry before and after a psychiatry clerkship (7). In this study 164 medical students were surveyed pre- and postclerkship during the 2002—03 academic year.
Students receiving clinical exposure to child psychiatry during the clerkship had a generally positive view of the specialty. The effectiveness of treatment for children with psychiatric disorders was endorsed. Students recognized that a shortage of child psychiatrists exists nationally. The perception of child psychiatry as a respected medical specialty was also increased. In spite of these positive attitudes toward child psychiatry, students continued to believe that lack of family and societal support of children with psychiatric illness was a significant problem.
The authors also examined attitudes toward general psychiatry. Student perceptions of general psychiatry were less likely to change following the clerkship. Specifically, patients were viewed as being unresponsive to treatment. The belief that general psychiatry was a respected medical profession, endorsed by only 53% of students, did not change following the clerkship.
Again, what might account for the results in this study? Many students interested in pediatrics are also likely to view child psychiatry experiences in a positive manner. Due to the close collaboration between pediatricians and child psychiatrists, respect for child psychiatry is also likely to increase. Many of the negative perceptions are similar to those encountered for psychiatry overall. The views that we treat only chronic patients who never get better, that our patients lack adequate social support systems, and that psychiatrists are outside the mainstream of medicine remain common among medical students.
A number of factors influence medical students’ attitudes about psychiatry and psychiatric illness, as well as their interest in psychiatry as a career choice. On an intuitive level psychiatric educators believe that good teaching and a quality educational experience during the psychiatry clerkship will improve student attitudes and interest toward psychiatry.
The two papers discussed here generally support that contention. In spite of the positive findings in these two studies, however, several disturbing trends continue. Among these is the belief that psychiatry is less respected than other medical specialties. This attitude very likely contributes to the lack of interest in psychiatry careers even after a positive clerkship experience.
How can we as psychiatric educators address these issues? It is essential that our profession identify barriers to medical student interest in psychiatry and develop specific intervention plans. Specific areas of intervention include many of the following:
1. Psychiatry clerkships should be increased in length rather than shortened. It is only through intensive, in-depth exposure to our field that students will come to fully appreciate what we do.
2. Clerkships should involve a variety of clinical experiences such as child psychiatry. Increased emphasis on outpatient psychiatry will also help students better appreciate what psychiatry is like in the "real world." The traditional inpatient psychiatry clerkship may actually increase students’ beliefs that psychiatric illnesses are generally untreatable and that our patients do not get better. Ambulatory care experiences may provide a more realistic picture of our specialty.
3. Students should also receive exposure to a variety of psychiatric subspecialties (e.g., geriatric and forensic psychiatry). These experiences will help students appreciate the tremendous clinical diversity that exists in psychiatry. This may be achieved by incorporating subspecialty rotations in the clerkship and also by developing extensive fourth-year electives in these areas.
4. Negative attitudes toward patients with substance use disorders emphasize the need to increase education about these disorders and their treatment. All students, regardless of the specialty they choose, will ultimately treat patients with substance use disorders. Psychiatry should take the lead in educating students about these disorders.
5. Psychiatric educators must find innovative ways to introduce students to our specialty. High quality clerkships containing a variety of clinical experiences represent one way to stimulate interest. The stigma associated with mental illness can be decreased by emphasizing the effectiveness of both pharmacologic and psychotherapeutic treatment. The introduction of psychiatric research into the medical student curriculum is one way to insure that students understand the scientific basis of our specialty.
6. Psychiatrists must maintain a high level of visibility in medical schools to reinforce to students our importance as a medical specialty. Mentoring of first- and second-year students is an essential element in fostering and maintaining a positive perception of psychiatry.
7. Most importantly, though, we must build and maintain a sophisticated curriculum, with strong outreach to medical students, across all 4 years of medical school. A psychiatry clerkship by itself is inadequate, regardless of length, to stimulate interest in and understanding of our specialty.
Medical students’ attitudes and perceptions of psychiatry impact a number of different areas. If students view our profession in a negative manner, their overall educational experience in psychiatry is likely to be diminished. Negative attitudes toward psychiatric illnesses will decrease the quality of care our patients receive from the physicians of the future. Strong interest in psychiatry and a positive view of our specialty are essential in order to recruit the best and brightest students. By focusing on these issues, we will strengthen psychiatry for the 21st century.
Dr. Feldmann is Associate Professor of Psychiatry, University of Louisville School of Medicine and President of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP)