The shortage of child and adolescent psychiatrists (CAPs) in the U.S. is well documented (1—3). In 1999, the Surgeon General determined that approximately 20% of children between the ages of 9 and 17 have psychiatric disorders (4). In addition, the population of children is projected to grow by over 35% by 2050 (5). Furthermore, the Council on Graduate Medical Education (COGME) reported that the nation would need more than 30,000 CAPs by the year 2000 (6). As of 2000, however, there were only 6,158 CAPs practicing in the U.S. (7). Given these numbers, we are facing a significant public health crisis.
CAPs generally enter their specialty training after completing a general psychiatry residency program. The number of U.S. medical students entering general psychiatry programs has increased in recent years (2001 = 524; 2002 = 564; 2003 = 597; 2004 = 641) but remains at less than 5% of all graduating students (8). Over the past few years, less than 125 U.S. medical school graduates per year have elected fellowship training in CAP (2001 = 92; 2002 = 98; 2003 = 90; 2004 = 120), filling less than 50% of offered positions (8). Such trends suggest that difficulties recruiting residents into CAP will continue (9).
Research has consistently found medical students to be relatively disinterested in psychiatry (10—13). Reasons for this lack of interest include concerns about the scientific rigor, respect, salary, therapeutic efficacy, and enjoyment as well as the belief that psychiatry utilizes only limited aspects of students’ medical training (11, 14—15). Little is known, however, regarding whether these same reasons apply to students’ decision-making when considering CAP as a career.
One study examined 17 variables for their ability to differentiate those interested in CAP from those interested in general psychiatry (16). Several variables were significant predictors of interest in CAP: prior elective coursework in pediatrics or a related subspecialty; being a woman; and not having attended a research-oriented or primary-care-oriented medical school. A second study of 24 students completing a CAP subrotation found that those who were positively influenced were also more likely to be women (17). In addition, students who were more likely to report a positive shift in attitude toward the field were interested in interpersonal facets of medicine (as opposed to teaching or research), were psychology or nonbiology majors in college, or were oldest siblings (17).
The purpose of the present study was to examine student attitudes toward CAP and general psychiatry at the beginning and end of their psychiatry clerkship. Our primary goal was to better understand the reasons why students reject CAP as a career choice and to examine whether such reasons differ between CAP and general psychiatry.
Third-year medical students (N=223) at the Drexel University College of Medicine served as subjects. Students were asked to complete an anonymous questionnaire on day 1 of the 6-week clerkship during the 2002—2003 academic year. Two hundred students (90%) completed the time 1 questionnaire. Students were again asked to complete the questionnaire on the last day of their clerkship (time 2, N=164, 74%). Students (52% male, 48% female) had a mean age of 26.4 years (SD=3.2). Fifty-six percent were European American, 16% Asian American, 10% Indian, 7% African American, 4% Latino, and 7% identified with another ethnic group. Students who failed to complete time 2 questionnaires were more likely to be single (χ2 =7.92, df=3, p<0.05) but did not differ from those who completed both time 1 and time 2 questionnaires on age, sex, or ethnicity. Students rotated at one of six clerkship sites. Approximately 55% of students rotated for 2 to 3 weeks on CAP inpatient units. All students, regardless of site, received a minimum of two formal CAP lectures.
The questionnaire included open-ended questions assessing student perceptions of CAP and general psychiatry. Questions included: "What are the positive aspects of practicing CAP"? "What are the negative aspects of practicing CAP"? These same questions were asked about general psychiatry, and student responses were coded based on their content. Students were asked: "Is there a shortage of physicians in CAP"? "Is there a shortage of physicians in general psychiatry"? "Is CAP a respected area of medicine"? "Is general psychiatry a respected area of medicine"? Additionally, students were asked to estimate the average income for both CAPs and general psychiatrists. Students were also asked in which area of medicine they planned to specialize. Only six (3%) students stated that they planned to specialize in psychiatry at time 1. Of these six, four still planned to specialize in psychiatry at time 2, while one was unsure and one failed to complete a time 2 questionnaire. Two additional students who did not initially plan to specialize in psychiatry, however, did plan on doing so at time 2.
First, student perceptions regarding the positive and negative features of CAP and general psychiatry were examined. Responses endorsed by 5% or more of students at either time 1 or time 2 for each question are listed in t1.
Students reported that the opportunity to help children was the most positive aspect of CAP. Other commonly endorsed positive aspects were the belief that children are more responsive to treatment and that CAPs have a flexible work schedule. For general psychiatry, students reported that increased patient contact, helping people, flexible work schedule, and working with diverse populations and problems were positive aspects. Student perceptions of the positive features of CAP and general psychiatry did not change from time 1 to time 2.
In contrast, student perceptions of negative aspects did change significantly over the course of their clerkship. For CAP, the percentage of students stating that CAP was emotionally stressful decreased by the end of the clerkship (from 30% to 18%; χ2=6.04, df=1, p<0.05). In contrast, the percentage of students who perceived lack of family or societal support for children (e.g., "cannot change the child’s environment"; "unsupportive families"; "many illnesses have a large social component that physicians have little impact on") to be the greatest negative aspect increased (from 7% to 17%; χ2=7.91, df=1, p<0.01).
For general psychiatry, there was a trend for students to increasingly perceive patients to be relatively unresponsive to treatment (i.e., 22% at time 1 to 30% at time 2; χ2=2.97, df=1, p<0.10). The percentage of students endorsing insurance problems (from 5% to 9%; χ2=2.99, df=1, p<0.10) or patient noncompliance with treatment (from 2% to 8%; χ2=5.74, df=1, p<0.05) also increased. In contrast, small decreases were observed in the percentage of students reporting that general psychiatry is emotionally stressful (18% to 14%; n.s.), stigmatized relative to other medical specialties (11% to 5%; χ2=4.42, df=1, p<0.05), and poorly paid (8% to 6%; n.s.). The most marked change, however, occurred in the number of students who were unable to rate a negative aspect of practicing general psychiatry, as this decreased from 16 students at the beginning of the clerkship to only 1 at the end of the clerkship (χ2=11.59, df=1, p<0.001), suggesting that the experience did provide them with a better understanding of potential challenges in general psychiatry. Thus, although there was no change in student reports regarding the positive aspects of CAP and general psychiatry, significant changes in students’ perceptions of negative aspects did occur over the course of their clerkship experience.
Most students, approximately 80%, were aware that there is a shortage of CAPs. This percentage did not change over the course of the clerkship. However, a distinction between CAP and general psychiatry was observed in student perceptions of respect. Whereas only 53% of students endorsed that general psychiatry is "a respected area of medicine," approximately 70% endorsed CAP to be a respected area. This difference was significant at both time 1 (χ2=14.23, df=1, p<0.001) and time 2 (χ2=7.95, df=1, p<0.01). These percentages did not change significantly from the beginning to the end of the clerkship.
Student perceptions of average annual income for CAP and general psychiatry were examined. Students rated CAPs’ salaries as significantly higher at the end of the clerkship (mean=$144,764 [SD = $45,512]) than at the beginning (mean=$130,089 [SD = $36,755] t =4.07, df=140, p<0.001). A similar trend was found for general psychiatry (time 2, mean=$129,968, [SD = $30,754] time 1, mean=$125,144 [SD = $27,958] t=1.95, df=146, p<0.10). Students rated CAPs’ salaries as higher than general psychiatrists, but only at time 2 (t=5.44, df=150, p<0.001).
Sex differences in perceptions were examined. The only significant difference observed was for positive aspects of general psychiatry at the end of the clerkship (χ2=15.70, df=4, p<0.01). Men were more likely to endorse flexible schedule/good hours as a positive aspect (37% versus 13%; χ2=11.32, df=1, p<0.001), whereas women were most likely to endorse helping people (30% of women versus 21% of men; n.s.), patient contact (21% versus 11%; χ2=3.16, df=1, p<0.10), and working with diverse populations/subject matter (29% versus 19%; n.s.) as the most positive aspects. A similar trend was observed for positive aspects of CAP at the end of the clerkship (χ2=7.56, df=2, p<0.10). Specifically, women were more likely to endorse helping children as the most positive aspect (65% versus 44%; χ2=6.54, df=1, p<0.05).
Several findings emerged regarding student attitudes toward CAP and general psychiatry. First, students reported that CAP is a respected area of medicine. In fact, more students perceived CAP to be respected than general psychiatry. Second, students felt that helping children, having a flexible work schedule, and believing that children are more responsive to treatment were positive aspects of CAP. Third, the two most frequently endorsed negative aspects of the field were its emotionally stressful nature and the perceived lack of family/societal support for children. By the end of the clerkship, students’ negative (but not positive) perceptions of the field changed. The percentage of students perceiving the field to be emotionally stressful decreased and the percentage of students reporting lack of family/societal support increased by the end of the clerkship. Also, students were more aware of the higher income potential among CAPs versus general psychiatrists at the end of their clerkship, though they still underestimated the average salaries as reported in national surveys (18).
Consistent with prior research (11, 14), we found that many students do not perceive general psychiatry to be a respected area of medicine. CAP, however, was perceived to be a respected area by approximately 70% of students. A number of factors may lead students to rate CAP as more respected than general psychiatry. Students may respect medical specialties that require longer training. Additionally, students may perceive general psychiatrists as unable to promote change in adult patient populations (e.g., those with schizophrenia). This was partially supported by the finding that the most commonly perceived negative aspect of general psychiatry was that patients seemed unresponsive to treatment. Because students must complete 3 years of residency in general psychiatry before specializing in CAP, negative impressions about general psychiatry may decrease some students’ interest in pursuing CAP. It is possible that more students would be interested in pursuing the field if there were alternate training pathways available, such as through pediatrics. It has been found that pediatric residents entering CAP training programs perform comparably to those who first complete a general psychiatry residency (19).
Another potential reason students may reject a career in the field is the perception that children’s families, and society in general, provide inadequate support for children’s needs, a perception that increased by the end of their clerkship. Perhaps students with this perception feel a lack of self-efficacy in creating positive change in the lives of their child patients, subsequently decreasing their interest in CAP. It is unclear whether students would have reported this negative perception had they been exposed to a more diverse patient population (i.e., middle as well as low socioeconomic status [SES] patients; outpatients as well as inpatients).
Low recruitment in the field may also be the result of underestimated earning potential. At time 1, students estimated the average annual income for child psychiatrists to be about $130,000. However, the average salary for newly trained child psychiatrists in the U.S. is $158,000 (18). Student estimates of CAPs’ salaries did increase by the end of their clerkship experience but remained lower than the national average.
Several limitations deserve mention. First, our data did not allow for a comparison of students who had a child clinical experience from those who did not. Hence, it is unclear whether a child experience may have influenced student perceptions of CAP. Second, we were unable to compare student perceptions across rotation sites. It would be interesting to know whether students who had exposure to low SES. chronic patients had more negative perceptions of CAP and general psychiatry than those who were exposed to more diverse patient populations. Finally, because our questions regarding the negative and positive aspects of psychiatry were open-ended, we were limited in our ability to track changes in perception over time. For example, although fewer students endorsed the "emotionally stressful" nature of CAP as a negative aspect postclerkship, it is unclear whether this perception actually decreased or, alternately, whether other negative aspects appeared more critical postclerkship.
Research is needed to further determine why relatively few students enter CAP programs. The 2001 American Academy of Child and Adolescent Psychiatry (AACAP) Task Force report on CAP workforce needs suggested that offering mentorship with a CAP, making child rotations interactive and rigorous, increasing teaching by CAPs in the basic science curriculum, and representation of CAP at career days may improve medical student recruitment into the field (20). More research, however, is needed to evaluate whether such interventions are effective in influencing student perceptions of the field. A previous study found that a 2 ½ hour weekly child experience utilizing a case method approach (i.e., interviewing a patient and discussing the case with an attending) positively influenced student attitudes toward CAP (17, 21). However, there are currently no national requirements for CAP training during the clerkship year. Given the significant public health issue raised by the shortage of CAPs, a required CAP experience may be indicated.
The authors thank Drs. Paul Ambrosini and Richard Malone for their assistance in reviewing earlier drafts of this manuscript.