Academic Psychiatry 27:235-237, December 2003
© 2003 Academic Psychiatry
Bullish on Psychiatry
Craig Van Dyke, M.D.
Dr. Van Dyke is Chairman of Psychiatry, University of California, San Francisco (UCSF), San Francisco, California and Director of the Langley Porter Psychiatric Institute, UCSF, San Francisco, California.
ABSTRACT
The number of medical students choosing to train in psychiatry is critical to our survival as a profession and to serving the mental health care needs of the American population. In two recent reports (1,2), the Surgeon General emphasized the prevalence of psychiatric disorders in the population, their morbidity and mortality, and the dramatic number of individuals who are not treated. Children and senior citizens are particularly underserved. Addressing these needs will require the training of more psychiatrists, especially child and geriatric psychiatrists, and a close and effective collaboration between psychiatry and primary care.
A number of factors influence medical student choice of specialty residency training (3–9). These include personal values, level of indebtedness, years of training for board eligibility, and specialty-related income. More recently, Dorsey and colleagues (10) called attention to the growing importance of a controllable lifestyle as a strong influence on medical student career choice. A controllable lifestyle was defined by personal time free of practice requirements for family, leisure, and avocation as well as control of hours spent on professional activities. They attributed the importance of a controllable lifestyle to several factors, namely an increasing number of women in medicine, decreasing professional autonomy, and large societal trends that place increasing value on avocational activities.
Another factor impacting the proportion of medical students matching into psychiatry residency programs (PMP) is the proportion choosing primary care residency training (e.g., family medicine, internal medicine, or pediatrics) (11). During the past 15 to 20 years, the trend has been that fewer medical students choose training in psychiatry as more choose training in primary care specialties. For instance, in 1987, 49.2% of medical students chose primary care residency through the match. By the early 1990s, this percentage decreased to 43.1%. As concern mounted about a possible shortage of primary care physicians and an overabundance of subspecialists, there was a concerted effort by the federal government and private foundations to generate interest in medical students to seek training in primary care specialties. In California there was even an agreement with the state legislature that the entire University of California system be required to devote at least 50% of their overall residency positions to primary care specialties. This occurred at a time when managed care was in its ascendancy and there was a perceived need for more primary care physicians. For mental health, the concept was that fewer psychiatrists would be needed because the vast majority of mental health problems would be diagnosed and treated by primary care physicians. In response to these efforts, the trend was reversed, and by 1998, more than 53% of medical students matched to residencies in family medicine, internal medicine, or pediatrics.
During the past 5 years, careers in primary care became less attractive as the market for their services contracted. Nurse practitioners and physician assistants began delivering a greater percentage of ambulatory primary care, and hospitals started to provide more inpatient care. There was also a consumer backlash against managed care and the "gatekeeper" model of care. Patients wanted direct access to subspecialty care. Currently, mounting evidence shows a decrease in career satisfaction with primary care, which is related to declining income and the growing disparity in income between primary care physicians and subspecialists. Additionally, there is increasing frustration with the limitations imposed by seeing patients for 10 to 15 minutes and being expected to respond to an extraordinary range of problems. As a result, only 44.2% of medical students matched to primary care residency programs in 2002, and this percentage is likely to decrease in the future.
What have been the trends for medical students choosing psychiatry as a profession? In the late 1980s, more than 5% of medical students chose psychiatry as a career. This decreased to 3.1% by 1998 and has gradually increased since then to 4.2% in 2002. Presumably the reciprocal relationship between the proportion choosing primary care training and the proportion choosing psychiatry training has to do with those medical students who place a high value on the doctor-patient relationship and less value on performing technical procedures. Medical students are aware that it is difficult to form a relationship with a patient in 10 to 15 minutes, which is the typical practice pattern for primary care. Psychiatry remains a field in which the physician can know the patient and develop a relationship. As dissatisfaction with primary care has increased, psychiatry has benefited through increased recruitment of medical students.
What can individual departments of psychiatry do to attract more medical students to the field? In this issue, Sierles and his colleagues (12) examine a number of regional and local factors affecting the number of medical students matching into psychiatry. They find that the best predictor of a school's PMP was its prior year PMP and there was a modest inverse correlation between PMP and the proportion of international medical graduates in residency training. Of note, the authors do not find a correlation between PMP and region of the country, medical school tuition, managed care penetration in the region, medical school admissions policy favoring rural applicants, length of psychiatry clerkship, ethnic composition of the medical students, publicly or privately funded medical schools, applicants stating an interest in primary care, or whether the dean was a psychiatrist.
The authors underscore the importance of a high-quality psychiatric education program offered by a department as the most important factor in determining PMP. This recommendation has face validity, especially since it is the factor over which departments of psychiatry have the most control. However, much more evidence needs to be gathered to support this contention. Since most medical students enter with little preparation or background in psychosocial issues, what do we need to teach in order to capture their attention and interest? As human genetics and neuroscience progress and become increasingly relevant to clinical psychiatry, what do we need to teach about these subjects (13,14)?
At the University of California, San Francisco (UCSF), the program with which I am most familiar, we have consistently had a high proportion of medical students (5% to 15%) choose training in psychiatry. In thinking about what might be the basis for our success, three factors appear important. First, our department of psychiatry has traditionally devoted significant resources to medical student education and has recruited outstanding residents who spend considerable effort teaching medical students. Within the medical student curriculum, we have a reasonable amount of time to teach psychiatry, and our efforts are rated highly by the students.
Second, our teaching faculty has occupied prominent educational roles beyond teaching psychiatry. For example, our director of medical student education directs the Foundations of Patient Care, the major interdepartmental doctoring course during the first 2 years of medical school. In addition, many members of our faculty teach small groups in this course. Another member of the psychiatry faculty has an educational role in the office of the dean and directs one of the five medical student colleges. These faculty members are perceived by students as excellent physicians as well as psychiatrists.
Third and perhaps most important are the values and admissions criteria of our school of medicine. The University of California, San Francisco prides itself on selecting a culturally diverse student body that reflects the demographics of California. Inherent in these students is a social commitment that is sincere and palpable. Many have worked in developing countries, for the underserved, and in socially committed organizations. They are interested in psychological issues and primed to be recruited into psychiatry. We are often preaching to the converted.
Psychiatry has a number of factors working in its favor that bode well for future recruitment, especially in an era when primary care training has less appeal. Our profession has a controllable lifestyle, a practice pattern that both permits and emphasizes the development of the doctor-patient relationship, and growing intellectual excitement as genetics and neuroscience unravel the mechanisms of the brain and mental illness. Moreover, our ability to treat psychiatric illness is improving at a very rapid rate. However, departments of psychiatry must do three things to improve recruitment: 1) They must offer outstanding educational programs to medical students 2) Psychiatry faculty must assume leadership roles in medical student education that are not confined to psychiatry, embracing all of medicine and portraying us as excellent physician role models. 3) Finally, we must influence the criteria and judgment about who is selected to medical school. Grades in organic chemistry and medical college admission test scores are not sufficient. Choosing students with a social commitment is critical to our future success in recruitment.
REFERENCES
- U.S. Public Health Service. Mental Health: A Report of the Surgeon General. Department of Health and Human Services, Washington DC, 1999
- U.S. Public Health Service. Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Department of Health and Human Services, Washington, DC, 2000
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- National Resident Matching Program Results and Data. Washington, DC, National Resident Matching Program; 2003
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