Acad Psychiatry 29:459-463, December 2005
doi: 10.1176/appi.ap.29.5.459
© 2005 Academic Psychiatry
Improving Recruitment and Funding in Psychiatry by Teaching College Undergraduates
Kenneth J. Braslow, M.D.,
Daniel J. Feeney, M.D.,
Glen R. Elliott, Ph.D., M.D.,
Kenneth L. Matthews, M.D. and
Anneke C. Bush, ScD, MHS
Received October 26, 2004; revised July 20, 2005; accepted July 28, 2005. Dr. Braslow is Child and Adolescent Psychiatry Fellow, the Children’s Center at Langley Porter, University of California at San Francisco, San Francisco, California. Dr. Elliott is also affiliated with the Children’s Center at Langley Porter, University of California at San Francisco, San Francisco, California. Dr. Matthews is affiliated with the University of Texas Health Science Center at San Antonio, Department of Psychiatry, San Antonio, Texas. Drs. Feeny and Bush are affiliated with the Wilford Hall Medical Center, Department of Psychiatry, Lackland Air Force Base, Texas. Address reprint requests to Dr. Braslow, University of California at San Francisco, 401 Parnassus Ave., Rm. LP 140, San Francisco, CA 94143-0984; kbraslow{at}lppi.ucsf.edu (E-mail). Copyright © 2005 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: To explore attitudes among leaders in psychiatric training about the usefulness of teaching college undergraduates about psychiatry and to assess benefits in recruitment and funding. METHOD: A survey of current practices and beliefs was sent to most adult and child psychiatry residency training directors (RTDs) and Chairs of academic departments of psychiatry in the U.S.). A follow-up survey was then sent to RTDs at responding programs that teach undergraduates. Interviews were also conducted with education experts to learn about the potential financial benefits of teaching undergraduates. RESULTS: Of the 289 (64%) respondents to the first survey, 237 (82%) expressed that teaching undergraduates might or would lead to increased recruitment. All RTDs at responding programs that offered courses answered the second survey, and four reported that undergraduate teaching brings in revenue. Experts confirmed the financial feasibility of these courses. CONCLUSION: Undergraduate psychiatry courses may increase overall recruitment and provide financial benefits for the departments that offer such courses.
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INTRODUCTION
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The effort to ensure sufficient recruitment is a battle in which academic psychiatry is perpetually engaged. Over the past decade, at most, 4% of graduating American medical students have gone into psychiatry, and they have only filled approximately two-thirds of the available PGY-I positions (1, 2). In 2002, the American Academy of Child and Adolescent Psychiatry (AACAP) designated recruitment as its highest priority (3). In 2004, 27% of child and adolescent psychiatry (CAP) residency training programs actively participating in the National Residency Matching Program had openings. (4).
Funding for academic psychiatry departments has also been decreasing. In 2000, Congress passed legislation that reduced indirect graduate medical education (GME) and disproportional share payments—both significant sources of dollars that eventually get distributed to individual departments (5)—by 15% and 3%, respectively (6). The field of CAP was particularly affected by legislation enacted in 1997 that cut direct GME funding by 50% for subspecialty training beyond the primary specialty board eligibility (7). Thus, academic departments could benefit from new sources of recruits and dollars.
One possible source of more trainees and funding that has received little attention is direct contact with university undergraduates. Little more than off-hand references to the notion of teaching undergraduates about psychiatry exist in the literature. To our knowledge, there has been no systematic examination of this idea. Yet there are college students who consider psychiatry as a career but who, intimidated by the rigors of a premedical curriculum, embark instead on the allied mental health paths of psychology, social work, nursing, or counseling. While the exact number of those who face this dilemma is not known, a 1984 study of 93 Chicago area psychologists revealed that 46% had contemplated going into psychiatry (8). Considering that, between 1995 and 2002 (the last year for which data were available), more than 70,000 bachelor’s degrees in psychology alone were conferred annually (9), a substantial number likely think about it. Students may perceive the allied mental health fields as having a greater benefit-to-cost ratio, and, in the absence of psychiatrist teachers, career choices may be modeled after those who are teaching—psychologists and other nonphysicians. Were these students exposed to psychiatry—and the opportunities it offers that other careers cannot—before ruling out going to medical school, perhaps they would be more inclined to face the rigors of medical training. Exposure to practicing psychiatrists would enable students to consider the perceived turmoil of premedical requirements, medical school, and residency in a greater context in which the fruit as well as the labor is clearer. It would also greatly facilitate the mentoring by attendings that is vital for recruitment and which traditionally does not happen until medical school, thereby missing a substantial percentage of potential recruits.
With an awareness that academic institutions have fiscal constraints, it is important to understand whether departments would lose money by teaching undergraduate courses, or might, instead, obtain financial rewards. Indeed, some universities designate funding specifically for undergraduate level coursework provided by academic departments. Many disciplines such as business, engineering and the basic sciences already follow this model and benefit financially from teaching at both the undergraduate and postgraduate levels (Isgar 2003, personal communication).
To review the literature on teaching undergraduates, we conducted a search on MEDLINE using the following terms and their various combinations: college, undergraduate, university, premedical, psychiatry, CAP, funding and recruitment. The results were sparse but encouraging.
The most germane publication is a case report on the undergraduate experience, about a freshman seminar at University of California, Los Angeles that started in 1979, in which 10 freshmen met for 3 hours, once weekly for one quarter, with a psychiatry faculty member in his office. The course presented introductions to general psychiatry, psychopathology and psychopharmacology. The authors concluded that "it was very encouraging that a significant introduction to both clinical and community psychiatry could be so enthusiastically and intelligently received in so short a time by so naive an audience..." (10). The article offered no data regarding career outcomes.
Medical students polled in 1981 stated that college classes had affected their "interest and respect for psychiatry." Of the 176 respondents, 20% said those classes "very much" increased it, and 40% said they had "somewhat increased" it (11). Moreover, 392 psychiatry residents surveyed in 1986 indicated that college courses were their most influential prematriculation factor (12).
Educators long ago acknowledged the importance of undergraduate influences. A 1981 national conference on the shortage of psychiatrists concluded that "college students should have more contact with psychiatrists through undergraduate course experience ... urgent attention should be paid to making explicit the value of a medical education for a mental health careerist so that high school and college age students will not be so likely diverted into psychology and related fields" (13).
Furthermore, in a 1997 comprehensive review of CAP recruitment, Beresin discussed the value of faculty mentors and supervisors for medical students and general residents in improving CAP recruitment. However, he did not explore the utility of extending this to undergraduates (14).
In 2003, Academic Psychiatry devoted a special issue to recruitment (15). Emblematic of much of the literature, it focused almost entirely on medical school and postgraduate education, not undergraduate education. Sierles et al. briefly mentioned a 1999 survey of 223 entering medical school students, which found that only one was considering psychiatry as a career choice (16) and suggested that a "prematriculation bias against psychiatry that cannot readily be explained by medical school factors" exists (17).
Our study aimed to assess whether educators believe teaching college undergraduates could improve recruitment and funding and if and how undergraduate psychiatry is currently being taught.
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Method
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Participants and Procedures
First, a nationwide survey on teaching college undergraduates was sent by e-mail and fax to 176 adult residency training directors (RTDs), 110 CAP RTDs, and 167 chairs of departments of psychiatry at academic health centers that sponsor adult or CAP residency programs. This represented all 182 general and 115 CAP residency programs. Contact information was obtained from FRIEDA, by visiting program web sites, or by calling directly. Respondents were asked to respond yes, no or maybe to eight questions, including if any of their department’s faculty psychiatrists teach a course on psychiatry to college undergraduates; if they believed teaching might lead to increased recruitment; if they thought teaching could lead to additional revenue; and, were there income to offset the expenses, if their department would be interested in pursuing teaching college undergraduates. Responses were then summed. At the end of the survey, respondents were encouraged to provide their own comments.
Second, a follow-up survey was sent to RTDs at programs that confirmed that they do teach undergraduates. Respondents were asked if teaching were a source of revenue for the department, and if so, did it exceed costs; who teaches the course; how long it lasts; how many students are in the course and at what grade level; whether it fulfills a general education requirement; what the curriculum focuses on; and what the primary reason is for teaching the course. Responses were then summed, averaged, or reviewed as appropriate.
Finally, three interviews were conducted to learn about the funding and curricular process with doctoral-level individuals knowledgeable in educational policy who were available locally.
The study was approved by the Wilford Hall Medical Center Institutional Review Board. All recipients were informed that they were taking part in a study, and they expressed consent by choosing to complete and return the questionnaire.
A particular statistical problem was encountered with those occupying dual roles—chairs in charge of multiple programs, chairs who were also RTDs, or those who were both adult and CAP RTDs. Chairs in charge of multiple programs were counted only once, because analysis under that subgroup would have been unfairly biased. Chairs who were adult RTDs and those who were both adult and CAP RTDs had their survey counted once under each category, because correspondence with them confirmed that their responses were the same from both vantage points.
Data Analysis
Overall, descriptive statistics were used to measure the various responses to the individual questions, but confidence intervals were not determined because the sample was finite.
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Results
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Survey on Nationwide Practices and Beliefs
Just under two-thirds (289 out of 453) of all recipients replied to the first survey: 90 (54%) chairs, 119 (68%) adult RTDs, and 80 (73%) CAP RTDs. Total response rates varied for each question but ranged between 281 and 289.
One hundred eleven (38%) respondents thought that teaching undergraduates would lead to increased recruitment, and 126 (44%) thought it might (see Figure 1 for breakdown by respondent type). Furthermore, if the course were taught by a psychiatrist rather than a psychologist, 165 (57%) felt recruitment would be better and 93 (32%) thought it might be.
Only 32 (11%) thought teaching undergrads would be an additional source of funding for their department, while 172 (60%) thought the opposite. The remaining 85 (29%) thought it might.
If departments could be sure that teaching would bring in additional dollars, 102 (36%) said they would be interested in providing an undergraduate course, and 85 (30%) thought they might be interested. If it brought in enough to more than break even, another 74 (26%) would be interested (see Figure 2).
In terms of setting, 100 (35%) respondents spent most of their time on the undergraduate campus, 134 (47%) were on a different campus than the undergraduate one, two (1%) were on both, and 52 (18%) said there was no undergraduate campus.
Fourteen respondents (5%), comprising 10 programs, reported that at least one psychiatrist on faculty teaches an undergraduate course on psychiatry.
Under the comments section, certain themes against teaching college undergraduates recurred: that psychologists already teach undergraduates; that they might object to psychiatrists teaching, for political reasons; and that very few resident candidates come from a psychological background.
Survey on Current Offerings
RTDs at all 10 programs that reported teaching undergraduates responded to the survey on course characteristics. These classes last from 60 to 90 minutes, with the majority lasting 90 minutes; meet from one to three times per week; and last from 10 to 20 weeks (most commonly 13 or 15 weeks). All are offered once per year. Five of them meet with 20 or fewer students, two with 90 to 100, one with 200, one varies between 30 and 100, and one did not specify the number. Six are taught by full-time psychiatry faculty, four by volunteer; seven offer general education credit; and half are offered to underclassmen, half to upperclassmen.
Three programs each were located in the midwest and northeast, and two each were located on the west coast and in the mid-Atlantic region. Three of the programs reported that it brings in revenue, and one was funded by a grant. On the condition of anonymity, one reported that approximately $10,000 per year is brought in; the others elected not to provide such data.
Courses ranged from having clear relevance to our field—for example, child psychiatry disorders; marriage and family; love and attachment; the history of psychiatry; creativity in mood; psychoneurobiology; and contemporary issues in mental health research—to broader topics from a psychiatric perspective, such as "Tragic Drama and Human Conflict" and "Self and Other in Greek and Hebrew Civilization."
Reasons cited for teaching include: being of personal interest of the faculty or university; exposing students early on in their careers to research in mental health; and teaching students about the impact of a healthy life style on mental health.
Interviews With Experts
Discussions revealed that significant monies can be made, even for those classes that do not currently bring in revenue. Teaching undergraduates can generate money because some universities allocate a portion of incoming tuition dollars generated by courses back to the course’s sponsoring department. Thus, programs may wish to discuss how they can receive funding with the dean of administration or finance at their institution. Furthermore, programs may be able to generate new extramural gifts, grants, contracts or endowments as well (Cooper, personal communication, 2003; Goldman, personal communication, 2003).
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Discussion
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Teaching undergraduates uniquely offers access to a new population of potential recruits to psychiatry. This article has presented empiric support in the literature and shown potential support at some colleges. It has explored current attitudes and practices among those responsible for psychiatry training and illustrated characteristics of courses currently being taught.
One common argument made against teaching undergraduates, however, was that psychologists do a good enough job of teaching these courses already and that they may not want psychiatrists encroaching. Unfortunately for recruitment into psychiatry, students who do indeed identify with the quality of the course presented by a psychologist may very well be more inclined to become psychologists. They may not have any balance from a psychiatrist to help them weigh their career options.
Another argument against teaching was that few psychiatry residents come from a psychology background. On the contrary, this actually strengthens the argument for teaching—it is this kind of course that could attract those with a psychology background before they venture down the doctoral or other allied mental health paths. Browsing the course catalog, some students would naturally be curious about a course taught by an M.D. Down the pipeline, then, there could be increasing numbers of residents from psychology backgrounds.
An additional argument against teaching could be that too many variations occur between college and residency for one college course to change recruitment. Yet if enough programs offer courses, then it would not take many students from each class to significantly help recruitment.
Our survey and interviews suggest that undergraduate courses about psychiatry can be introduced on a cost-neutral or even cost-positive basis. Yet at some institutions where teaching undergraduates would not be financially rewarding, volunteer faculty may be able to minimize the cost. As there may be community practitioners who wish to be involved only in teaching anyway, this could be a mutually beneficial use of their time. Even psychiatrists who merely guest lecture in liberal arts courses may pique the curiosity of students, which could be a means of recruiting students into medical schools and psychiatry.
Finally, lack of an undergraduate campus need not be a barrier to implementation. Three of the 10 programs that currently offer a course go off their medical campus to provide it. Furthermore, it is possible that faculty could teach at a nearby college not affiliated with their medical school.
Limitations
First, while our surveys appeared to have face validity, no reliability testing or validation studies were done because the surveys were generated specifically for this study. Second, a response rate of 65% raises concerns about the generalizability of our findings. Moreover, the fact that only 10 programs reported teaching undergraduate psychiatry at this time makes a small sample from which to extrapolate the quality of that experience. Furthermore, our findings are based on retrospective reviews and anecdotal beliefs; there is no prospective data that shows a causal link between teaching and improved recruitment. Finally, the impact of these courses in terms of a department’s role in the university and community, burden on the faculty, and recruitment warrants further research.
Conclusions
Teaching psychiatry at the undergraduate level could be a new source for recruitment and funding and would, in and of itself, contribute to the education of young people, which might be one way to decrease mental health stigma. It could show future potential psychiatrists that a light exists at the end of the tunnel of premedical and undergraduate medical education and that the hard work they would endure in organic chemistry and gross anatomy could lead them to a most rewarding career in psychiatry.
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ACKNOWLEDGMENTS
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The authors thank Dr. Rachel Isgar and Dr. Robert Cooper, both of the University of Southern California, and Dr. Greg Goldman, of the University of California at Irvine, for their contributions.
This study was presented in part at the 157th Annual Meeting of the American Psychiatric Association, New York, May 1-6, 2004.
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ABSTRACT
INTRODUCTION
