In many countries there has been an increasing concern regarding the low number of medical students choosing psychiatry as a career at graduation (1). For example, U.S. studies (2, 3) have pointed out a steadily decreasing trend in recruitment for many years. Specifically, since the mid-1970s enrollment has been generally decreasing, from 5.9% in 1978 to 4.1% in 2008 (4) reaching the lowest proportion in 1994 (3.2%).
This decline has led to an interest in attitudes and opinions of medical students toward psychiatry. In a U.S. study with freshmen students, psychiatry rated significantly lower than other specialties with respect to scientific precision, drawing on all aspects of medical training, and the enjoyment of work (5). Frequent postrotation criticisms allude to the lack of treatment efficacy, the low status of psychiatry among medical specialties, and the lack of respect by other specialists and house staff (6).
Findings from the United States (2) and other countries (7, 8) illustrate that the difficulty in recruiting physicians into psychiatry is unlikely due just to negative opinions. However, the gradual globalization of medical and psychiatric education (1) has revealed that these criticisms could be different depending on the country. For example, the opinions of Spanish students about the biopsychosocial concept of illness, salary, social pressure, and respect from nonpsychiatry staff were different than those of U.S. students (7). The stigma of medical students against psychiatry and psychiatrists was stronger in Ghana than in the United States, but students received less discouragement from families and fellows than their U.S. counterparts (8).
This wider point of view suggests that opinions can be affected highly by sociocultural contexts and that some sociocultural factors can play a role in students’ perception of and recruitment into psychiatry.
Our study assessed the role of opinions of medical students toward psychiatry on recruitment rates in two countries with different sociocultural context but the same language (Spain and Colombia).
The medical school of the Autonomous University of Barcelona (UAB) was founded in July 1968. The undergraduate syllabus of a physician’s education in Spain consists of 3 years of basic and preclinical sciences and 3 years of clinical and preventive subjects. From years 3 to 6, UAB students rotate at four general hospitals in Barcelona. UAB undergraduate training in psychiatry lasts 100 hours (6 weeks in year 5): 35 hours of theory and 65 hours of clinical rotations in various departments such as emergency, substance abuse, neuropsychology, and outpatient and inpatient units.
The medical school of the University of Antioquia (UA) in Medellín, Colombia, was founded in 1871. The UA medical syllabus is divided into 12 semesters with a greater mix of basic and clinical subjects than at the UAB. Undergraduate training in psychiatry consists of 117 hours during the eighth semester: 28 hours of theory and 89 hours of practice, similar to UAB but without substance abuse and neuropsychology rotations. However, at UA there is a greater emphasis on consultation-liaison psychiatry than at UAB. Although education at both schools understands mental illness within the biopsychosocial model, UA is more influenced than UAB by a psychodynamic background due to the widespread practice of psychoanalysis in some South American countries.
The UAB and the UA cooperate institutionally by promoting academic, scientific, and professional relationships, and exchanging teachers and students. This circumstance and our experience with these countries determined our choice of these countries and medical schools for this study.
The study participants included medical students from UAB and UA who volunteered to complete the study questionnaires. Following a cross-sectional design, we administered a questionnaire based on that by Nielsen et al. (6), adapted by Balon et al. (2), and translated from English into Spanish (full questionnaire available from the authors upon request). Balon et al.’s questionnaire consisted of 29 questions that explored the attitudes of medical students toward psychiatry according to six aspects: overall merits of psychiatry, efficacy, role definition and functioning of psychiatrists, possible abuse and social criticism, career and personal reward, and specific medical school factors (this aspect was only answered by those students who had completed the psychiatric rotation).
We recorded sociodemographic characteristics such as gender, age, and academic year. The choice of medical specialty was also gathered, with special emphasis on interest to enroll in psychiatry, with five possible answers grading from “I have never considered it” to “I will enroll in psychiatry.” Finally, questions about “feeling well trained in attending psychiatric patients after my psychiatric rotation” and “having lived together with a psychiatric patient for at least 1 year” were added to see to what extent the learning processes and emotional experiences could be involved in recruitment.
The only formal criterion required for participation in the study was to be an enrolled medical student. Permission from various coordinators of educational institutions was requested, and copies of the study protocol were sent to them. A written explanation of the study’s purpose preceded the questionnaire. It was explained to the students that responses were absolutely anonymous and voluntary, and that there were neither academic nor social consequences to their participation. Returning an anonymous questionnaire was considered to imply informed consent. Due to these circumstances, our ethics committee considered this study exempted from approval.
Because of increasing evidence that the rotation influences students’ attitudes toward psychiatry (9, 10), we included a later analysis to evaluate the effect of the rotation on the differences in the opinions between both groups. Although the questionnaire by Balon et al. (2) admitted four degrees of agreement for each item, we combined them into two: agree and disagree. Statistical analysis was performed with SPSS version 15.0 software (Chicago, 2006) using chi-square, Student’s t test, and Mann-Whitney U test.
A total of 582 students participated: 207 students (35.6%) from Barcelona and 375 (64.4%) from Medellín. Of these, 117 students (56.5%) from Barcelona and 171 students (45.6%) from Medellín had not rotated through psychiatry. The gender distribution was 57 men (27.5%) in the Barcelona group and 167 men (44.5%) in the Medellín group (χ2=16.48, p=0.000). The mean age of the Barcelona students was 20.9 years old (SD=4), and mean age of the Medellín students was 21.9 years old (SD=3.2) (t=−3.47, p=0.001).
Opinions Toward Psychiatry
Table 1 shows the significant differences of opinions between Barcelona and Medellín students. Table 2 shows the significant differences of opinions between both groups, but includes only students who completed the psychiatric rotation.
Students who lived with someone who had mental illness (Figure 1; Mann-Whitney U p=0.001) and those who felt well trained (Figure 2; Mann-Whitney U p=0.049) showed more interest in choosing psychiatry. Among 16 possibilities of medical specialties, psychiatry was chosen by 9.7% of students from Barcelona and by 4.3% of students from Medellín. Among the postrotation group, psychiatry was chosen by 14.4% in Barcelona and 5.4% in Medellín.
In general, the students from Barcelona and Medellín had a positive view of psychiatry. However, students from Barcelona agreed more with the high scientific status of psychiatry, the social prestige of the specialty, and seemed to be more interested in choosing it. These main differences held in the analysis included only students who had completed the psychiatric rotation. Students from Medellín felt less supported for choosing psychiatry than students from Barcelona. Specifically, living with people who have mental illness and feeling prepared in attending patients were related to more interest in choosing psychiatry.
The differences can be partly explained by the sociocultural contexts of Barcelona and Medellín. For example, students from Barcelona (where the neuroscientific model has greater influence) agreed more with a medically oriented position of psychiatry and that psychiatry is scientific, precise, and a valid branch of medicine. However, the view of psychiatry as a rapidly expanding frontier of medicine was more frequent among Medellín students, maybe because the transition toward psychiatry within the context of a general hospital took place later in Medellín than in Barcelona.
Despite differences in the theoretical position of psychiatry between Barcelona and Medellín, most students preferred psychiatry to be more biological and more attentive to the patient’s psychological problems. However, students from Medellín (where the psychodynamic model has greater influence) stated more that psychiatry should be more “biologically” oriented, but this difference disappeared with the learning process.
Regarding efficacy/helpfulness of psychiatry, Medellín students agreed more with the usefulness of psychiatric consultation, probably due to its greater promotion in the University of Antioquia. These differences disappeared in the postrotation analysis. As reported in previous works (11, 12), the experience of psychiatric rotation usually leads to higher appreciation of the therapeutic potential of psychiatric interventions.
Students from Medellín expressed a worse social image of psychiatry. Sixty-five percent (n=238) felt that psychiatry had low prestige among the general public, 25% (n=86) stated that many psychiatrists had no real vocation, and almost 40% (n=140) felt social pressure if they expressed interest in psychiatry. Shifting this image (to some extent by institutional support for the student’s choice) during the rotation period is an essential part of the educational process, not only for students interested in psychiatry, but also for general practitioners, who play an important role for patients with mental illness (13).
It is difficult to say whether different recruitment rates between the two countries can be only explained by differences in opinions. The higher rate of psychiatry choice among Barcelona’s students might be related to the greater perception of scientific status and social prestige of psychiatry. However, to overcome prejudice and generate a deep understanding of the strengths and weaknesses of psychiatry, the learning process should include both favorable and critical opinions. Thus, a training strategy to improve recruitment might be to allow constructive criticism. Our results show that individual emotional experiences like living with a mentally ill person could play a valuable role in psychiatry choice. As pointed out in other studies (14, 15), feeling prepared to care for patients and the perception of greater institutional support for the student’s choice could also be related to recruitment.
Our study has several limitations. First, it is difficult to gather multicausal personal opinions as well as social and cultural values with a questionnaire. Second, the results were obtained from only one university in each country, and our findings might not necessarily apply to the entire medical school populations of Spain or Colombia. Third, the comparison groups were not entirely homogeneous (with respect to age and gender). Nevertheless, we believe that the use of direct comparisons, the preservation of anonymity, and the forced-choice nature of the questionnaire allowed us to elicit a realistic reflection of the students’ perception of psychiatry. In conclusion, the results of our study suggest a possible role of sociocultural context in students’ perception of psychiatry.
FIGURE 1. Frequencies of Students Living With Mentally Ill Patients and Showing Interest in Choosing Psychiatry*
*Includes both students who have completed and students who have not completed psychiatric rotation
FIGURE 2. Frequencies of Students Feeling Well Trained in Attending Mentally Ill Patients and Showing Interest in Choosing Psychiatry*
*Includes only those students who have completed psychiatric rotation
The authors thank Anna L. Subira for the translation tasks and Serge Mojal for the methodological and statistical assessment (Department of Methodological Consulting in Biomedical Research, Barcelona, Spain, Biomedical Research Park–CSB–IMAS).
At the time of submission, the authors declared no competing interests.