Recruitment has been a topic of interest in the field of psychiatry for many years (1). While psychiatrists may disagree as to whether or not a “recruitment crisis” exists, most acknowledge that psychiatric educators should remain committed to two main goals: 1) providing every medical student with an excellent educational experience and 2) recruiting U.S. medical school graduates into the field (1–4). Most published surveys exploring psychiatric career choice focus on the characteristics and the attitudes of medical students who choose psychiatric residencies. In general, these students tend to be older nonscience majors who are more empathic and verbally skillful. Many have had a personal experience in psychotherapy or with a psychiatrically ill family member (1, 3–10).
Some attitudinal studies have included all medical students rather than exclusively students whose specialty choice is psychiatry. The available evidence suggests that medical students hold mixed views of psychiatry—that they perceive it as a valuable and interesting field with favorable hours and working conditions (11), but they also perceive that the field affords low status, has low earning potential, and treats chronic patients who do not necessarily get better (1, 12). In addition, previous reports note that advanced medical students are concerned that their faculty and their families regard psychiatry as a poor utilization of their medical degree (12, 13).
Indeed, recent prospective studies have had conflicting results with regard to whether students’ attitudes about psychiatry have become more positive (14) or less (15). For example, even positive reports by students—where psychiatry is described as a useful and valid field—are tempered by their persistent concerns with low status and income as well as their discomfort with psychiatric patients (14). Some studies indicate a decline in interest in psychiatry when comparing premedical school preferences and postgraduate residency choices at northeastern medical schools (16). Similar results were also found when students were surveyed at three distinct time points: 1) prior to their medical school psychiatry curriculum; 2) immediately after their medical school psychiatry curriculum; and 3) again as senior house officers (17).
In this article, we consider the extent to which the recent relatively low recruitment rates reflect a negative opinion about psychiatry among medical students. This possibility is of concern for two reasons. First, are we as a field doing all that we can to enhance the educational experience of all medical students, regardless of their career preferences? Specifically, since our students represent our future medical colleagues and given that they will see many psychiatrically ill patients throughout their careers, their psychiatric exposure must provide them a framework to identify psychiatric illness, make appropriate referrals, engender empathy, and minimize stigma toward psychiatric patients. Second, what are the most appropriate ways to encourage interested medical students that would allow for more targeted recruitment efforts toward receptive students?
We explored the ways in which a low recruitment rate actually indicates a negative view of psychiatry. Specifically, we examine students’ perceptions of psychiatry within the context of their self-reported level of interest in a psychiatric career. To do so, we compared medical students who indicated that they were potentially attracted to a career in psychiatry with students from the same class cohort who identified themselves as uninterested in the field. There were three goals to this investigation: 1) to offer an updated assessment of medical students’ perceptions of psychiatry; 2) to evaluate the personal, educational, and social contributors that led to those perceptions; and 3) to explore how those perceptions possibly influence the students’ career decisions.
This study was conducted with two classes of students between 1995 and 1996 at a northeastern, urban, private university medical school. There were 131 third-year students (90% of the total class) and 117 fourth-year students (75% of the total class) who responded to the survey.
Anonymous self-report questionnaires were developed by one of the authors of this study and face-validated with three other teaching faculty members. The items were then piloted with 44 fourth-year medical students as a check for the suitability of the questionnaire for its intended use (unpublished data). After revising the questionnaire based on these data, we contacted students according to Institutional Review Board approved protocol.
Participants initially rated the degree to which they considered psychiatry as a career both before and during medical school on a 10-point scale concerning: 0 = “never entered my mind” and 9 = “came to medical school to be a psychiatrist” before medical school and “plan to match in psychiatry” during medical school. Background and demographic information were also collected. Subsequent items concerning psychiatry’s intellectual interest; status among faculty or house-staff, family, and society; earning potential; impact of health care reform; quality of life; and satisfaction of working with psychiatric patients were included. Among fourth-year students, an item regarding the stress of working with psychiatric patients was also included. This item was removed for third-year students because they were still in the midst of choosing a career (see Discussion section on stress).
Third-year students were instructed to indicate (on a scale of −5 to +5) the degree to which each factor influenced them toward or away from psychiatry as a final career choice. The survey was personally distributed to students from all clerkship sites and collected by one of the authors on the last day of their psychiatry clerkship throughout one academic year. The questionnaire included no personal identification and was collected for the entire year before it was reviewed, ensuring students further anonymity of their responses.
Based on analysis of the pilot study responses (unpublished), the fourth-year student questionnaire was subsequently modified to obtain two separate and more distinct variables: positive ratings and negative ratings of the same factors (e.g., intellectual interest) (on scales of −6 to 0 and, separately, 0 to +6). Students were instructed to choose ratings for each factor on both scales. The change in the scale from 5 (third-year students) to 6 was inadvertently made at the time that the scale was drafted to include both positive and negative ratings for fourth-year students. Students received the questionnaire in the mail approximately 2 months before their graduation. All fourth-year students were compensated $20 for returning a completed questionnaire due to a relatively low response rate obtained in the previous pilot study using a mail-distributed survey.
For the initial descriptive analysis, simple mean comparisons were used to explore whether the degree to which students considered psychiatry as a career choice changed over time. For the main analysis of interest, participants’ consideration of psychiatry as a career choice was the independent measure.
For the independent variable, respondents were divided into two groups based on their expressed level of interest in psychiatry during medical school. The mid-point of 5 on the response scale rating interest in a psychiatric career was chosen to divide and then classify respondents. Those students rating their interest as greater or equal to 5 either before or during medical school are referred to as seriously considered (SC) students. Those students rating their interest as less than 5 both before and during medical school are referred to as never seriously considered (NSC) students.
The dependent measures were the participants’ numeric rankings of the impact of psychiatry’s intellectual interest, status, earning potential, and quality of life, as well as the anticipated effects of healthcare reform, the satisfaction of working with psychiatric patients, and—for the fourth-year students only—stress on their consideration of a psychiatric career. Using simple mean comparisons, we conducted an analysis of variance (ANOVA) to test for significant differences between variables of interest. In order to reduce error due to multiple significance tests for analysis of the factors affecting consideration, all comparisons are reported using a Bonferroni-adjusted significance level.
Finally, an additional analysis determined the extent to which background demographics such as age and undergraduate major differed between the SC and the NSC groups.
Degree of Career Consideration
The degree to which all students reported having considered a career in psychiatry increased significantly when comparing each student’s “before medical school” to his or her “during medical school” ratings (M=1.3, SD=3.1), p<0.001 (paired-t).
Sixty five (49%) of the third-year students were classified as having seriously considered (SC) a psychiatric career and 66 (51%) as never seriously considered (NSC). The mean degree of expressed interest in a psychiatric career for the third-year group differed significantly between the SC students (M=5.5 [SD=2.3]) and the NSC students (M=1.8 [SD=1.5]), p<0.001.
For the fourth-year students, 32 individuals (27%) were classified as having seriously considered a career in the field of psychiatry. Here, the mean degree of expressed interest in a psychiatric career also differed significantly between the SC students (M=6.0 [SD=1.7]) and the NSC students (M=1.6 [SD=1.5]), p=0.001.
For the third-year student cohort, SC students were slightly older (M=26.8 [SD=2.8] versus M=25.6 [SD=2.6]), p=0.02, and were more likely to have had personal exposure to psychiatry through either their own psychotherapy or a family member’s psychiatric treatment (54% SC versus 29% NSC), p=0.006.
For the fourth-year cohort, SC students were significantly more likely to have had personal exposure to psychiatry through either their own psychotherapy or a family member’s psychiatric treatment (63% SC versus 38% NSC), p=0.03. In addition, the fourth-year SC students were significantly more likely to have matched in a nonsurgical field (75% SC versus 52% NSC), p=0.04. Also evident in this cohort was that the SC students were significantly more likely to have majored in a nonscience (defined as psychology, humanities, or social sciences) as opposed to a science (defined as natural science, engineering, or mathematics) in college (56% SC versus 34% NSC), p=0.04.
Factors Affecting Consideration
As shown in Figure 1, all third-year students identified the intellectual content of the field and quality of life issues as the more highly considered contributors to their interest in psychiatry. In fact, among NSC students, intellectual interest and quality of life were the only positive factors. As can also be seen in Figure 1, comparisons between the SC and NSC groups revealed significant mean differences for the following: 1) intellectual interest; 2) status among faculty and house staff; 3) quality of life; and 4) satisfaction of working with psychiatric patients.
Figure 2 shows the summation of the fourth year students’ positive and negative ratings for the impact of each factor. For example, if a student rated the positive effect of earning potential as a 1 (0 to 6 scale) and the negative effect as a −4 (−6 to 0 scale), then the summed score would be a −3. As can be seen, all fourth-year students identified the intellectual content of the field and quality of life issues as the most important contributors to their interest in psychiatry. Again, among the fourth-year NSC students, intellectual interest and quality of life were the only positive factors. For the SC and NSC groups, significant mean differences were found for psychiatry’s intellectual appeal. Regarding satisfaction of working with psychiatric patients, there were also significant differences between the two groups: the SC group’s average rating was marginally positive (M=0.8 [SD=2.9]) while the NSC group’s rating was somewhat more negative (M=−1.5 [SD=3.2]).
Regarding the factor of “stress of working with psychiatric patients,” which only the fourth-year cohort rated, there was no difference across SC and NSC groups in the degree to which respondents reported that stress influenced them. Both groups ranked stress negatively, indicating that SC students were equally concerned as were NSC students that working with psychiatric patients would be stressful.
These findings replicate previous reports that older nonscience majors tend to be particularly interested in psychiatry and that students tend to associate the field with an attractive lifestyle (11). Regarding intellectual content, it is reassuring that students rated this as appealing. This suggests that the educational program successfully conveys the excitement of the current intellectual environment in psychiatry. Nevertheless, it is impossible to ignore the striking contrast between the degree to which students find psychiatry to be an intellectually stimulating field that offers an attractive lifestyle and the low rate that this group of medical students chooses it as their specialty. More specifically, despite the relatively high reported interest in psychiatry among this sample of third- and fourth-year students, only three or four individuals from each class cohort actually chose psychiatric residencies. Some individuals do return to the field in later years (18, 19).
All respondents, irrespective of their class or their level of interest in a psychiatric career, generally rated the following factors as having had a negative impact on their interest in the field: 1) status of psychiatry in society at large, 2) psychiatrists’ earning potential, and 3) the possible impact of health care system changes on psychiatric practice. These negative influences are, however, characteristics of the field over which psychiatric educators have little influence.
Addressing areas of influence that may be more in reach, our data suggest that psychiatric educators should attend to two additional factors that were shown to have a significant impact on students’ consideration of the field: 1) perceived levels of satisfaction; and 2) stress in working with psychiatric patients. Indeed, it is interesting that while the students who seriously considered a psychiatric career reported being significantly more positively influenced by psychiatry’s life style and the satisfaction of working with psychiatric patients, they also reported equal levels of concern about the expected stress of working with psychiatric patients as the students who never seriously considered a psychiatric career. This finding suggests that addressing students’ perceptions of stressful experiences should be a high priority.
We acknowledge that our data allow us only to speculate as to the meaning of stress to our participants. From the literature, we know that there are different interpretations of stress by students with regard to their exposure to psychiatry. For example, future senior students committed to careers in psychiatry described feeling “challenged” in their work with psychiatric patients, whereas students not choosing psychiatric careers felt that the adjective “frustrated” best captured the experience (20). We believe efforts should be made for all students to experience feeling competent, effective, and not overly stressed wherever the setting of their psychiatric training. At the same time, it must be recognized that stress may be an unavoidable component of the third year student’s psychiatric rotation (21, 22). Nevertheless, we would not advocate merely reducing hours or patient exposure in order to minimize stress, as we may then be left with students who are disengaged and dismissive of a field with an “easy” clerkship (20).
As an example of an application of our findings, we have now added to our clerkship orientation for students the following components: a) an acknowledgment that many students report feeling “stressed” during the psychiatry clerkship, b) a brief discussion of possible contributors to that stress (more intense interactions with patients than on other clerkships, severity of psychopathology of patients, developmentally appropriate tendency of students to overidentify with patients), and c) reassurance that practicing psychiatrists are able to be empathic without feeling overly responsible or merged with their patients and thus do not generally experience high levels of stress.
Our working hypothesis regarding medical student stress on the psychiatry rotation is that open discussion will alleviate such concerns, provide a context for the intense emotions that the students may experience during the clerkship, and contribute to all students’ development of the necessary emotional tools to handle such reactions. Regardless of specialty, these are the skills that all medical students will one day need as empathic physicians encountering psychiatric patients.
Openly discussing stress, which may appear as intuitive, is a significant change in policy for us. In fact, the question about “stress of working with psychiatric patients” was omitted from the survey given to the third-year students for fear of suggesting a concern that might not have otherwise occurred to students who had not yet made a career decision. In retrospect, we feel that it is preferable to make such concerns explicit. Educators should consider other options with regard to the timing and context of such discussions, including the preclinical years and throughout the psychiatric clerkship.
The results of this study are limited to one school and thus cannot necessarily be generalized. As a self-report survey, this study obtained students’ ratings on broad categories of their perceptions of a career in psychiatry. Thus, we can only speculate as to the specific concerns that are reflected in the ratings. Anecdotally, practicing psychiatrists generally feel that many options exist to treat patients more effectively than ever before. In contrast, we also see that recent trends toward shortened hospital stays result in either a more severely ill inpatient population or patients being sicker when they are discharged. This is an important consideration given that students participating in this study had their clinical experiences primarily on inpatient services. In addition, some educators have observed a higher recruitment rate for students assigned to an outpatient, as compared with an inpatient, setting (23). Perhaps a better balance between the two is necessary. Conversely, the outpatient environment is rarely an option as the major component of the clerkship experience because it requires more faculty time and supervision. Inpatient units offer the advantages of obvious psychopathology, close supervision, and continuity.
A better understanding of this complex decision-making process requires a more in-depth study. We are currently analyzing the results of interviews that were conducted with graduating medical students who were “on the fence” about psychiatry as a career choice as one such approach (24). In the meantime, based on our current data, we recommend that psychiatry clerkship directors attend to students’ perceptions of stressful experiences during the psychiatry clerkship in an effort to improve the educational experience for all students as well as a potential approach to increasing recruitment into the field.
FIGURE 1. Average Ratings of Factors Affecting Third Year Students’ Consideration of Psychiatry as a Career Choice
*The means differ at the Bonferroni adjusted significance level, p<0.00625.
FIGURE 2. Average Ratings of Factors Affecting Fourth Year Students’ Consideration of Psychiatry as a Career Choice
*The means differ at the Bonferroni adjusted significance level, p<0.005.
The authors thank Drs. Jean Endicott, Eric Marcus, and Ronald Rieder for assistance with study design, Dr. John Nee for initial data analysis, Alex Weiss for design of the figures, and Edith White for manuscript preparation. They also acknowledge the insightful comments of the two anonymous reviewers, which improved the manuscript significantly.
This study was supported by a grant from the Frontier Fund.