A Korean survey on qualities and definition of a good psychiatrist.

The definition of a "good" psychiatrist has varied over the past decades due to changing roles of psychiatrists. Studies on the qualities of "good" psychiatrists have been completed in many countries. However, no such study has been undertaken in Korea. In Korea, recent growing interest in psychiatry demands the identification of qualities for a good psychiatrist. The purpose of this study was to define the qualities of a good psychiatrist in Korea, subsequently facilitating the improvement of psychiatric training programs. The questionnaire was based on a Singaporean survey with the permission from the original authors. Respondents were divided into patient group and psychiatrist group. The 40-item questionnaire contained items grouped into four themes: Professional, Personal Values, Academic Executive and Relationship. Of the four themes, both patient and psychiatrist groups considered Professional as the most important, whereas Academic Executive as the least important. The mean scores for all items of each theme in the patient group were higher than those in the psychiatrist group, reflecting higher expectations for good psychiatrist in the patient group. Patients emphasized Relationship more than psychiatrists did. It is concluded that a good psychiatrist in Korea can be defined as "a good communicator and listener with a professional manner, who respects confidentiality and has good doctor-patient relationships."

INTRODUCTION

The definition of a "good" psychiatrist differs depending on who is being asked and what is being expected. Around 30 yr ago, a psychiatrist was defined as "a physician who has a skill to evaluate and treat mental disorders" (1). However, the role of a psychiatrist has changed and expanded extensively since then. Studies have been conducted in many countries to identify what a good psychiatrist is and what qualities are required for them (2). The Royal College of Psychiatrists published Good Psychiatric Practice (2000) containing the qualities and duties of a good psychiatrist, which has received regular revisions. In the most recent edition (the 3rd) (3), several standards of good psychiatric practice have been documented, including the standards of Good Medical Practice (4). According to Good Psychiatric Practice, psychiatrists are required to possess clinical competency, up-to-date knowledge and skill, strong communication and listening skills, good relationships with patients and their caregivers, ethical practice principles, and high awareness of patient boundaries and their vulnerabilities (2). By establishing detailed standards and a definition of "good psychiatric practice," the Royal College of Psychiatrists encouraged the development of those defined qualities in psychiatric residents not only during training but also after they pass the board examination (3). Mikhael (5) has suggested core competencies for specialty physicians that are comparable to those in Good Psychiatric Practice, emphasizing clinical competencies, good communication skills, integration of medical knowledge, and real-life practice. In Korea, standards of minimal academic requirement or psychiatrist are well documented in comparison to other countries. However, specific standards of good psychiatric practice or qualities to pursue in order to be a good psychiatrist have not been determined yet (6).

To our knowledge, no study has been reported on qualities of a good psychiatrist in Korea. In fact, there are very few studies on the qualities of good psychiatrists in Asian countries in general. Therefore, the objective of the present study was to identify the qualities of a good psychiatrist. This study will help improve the training of future psychiatrists.

MATERIALS AND METHODS

Subjects

Both patient group and psychiatrist group participated in this survey. For the patient group, participants were recruited from the outpatient populations of 10 collaborating psychiatric hospitals in Korea.

For the patient group, the inclusion criteria were outpatients who visited the psychiatric clinics with age between 18 and 65 yr. Exclusion criteria were patients who had severe psychotic symptoms that disturbed their ability to read or understand the survey and those who had a diagnosis of moderate to severe mental retardation or dementia based on DSM-IV-TR criteria.

For the psychiatrist group, inclusion criteria were psychiatric residents or psychiatrists in Korea with age between 18 and 65 yr.

Measures

The questionnaire used in this survey was the same as that used in a Singaporean survey (7), with permission obtained from the original authors. The questionnaire consisted of 40 items measuring qualities considered to be required for good psychiatrists, as determined by a Singaporean focus group (7). The respondents were asked to rank the importance of each item on a 5-point scale, ranging from 0 to 4.

First, the questionnaire was translated into Korean by two psychiatrists. A third Korean psychiatrist revised the initial translation. The questionnaire was then translated from Korean into English by a bilingual physician. Any potentially ambiguous English words received a liberal Korean version after discussion with the original author. After that, the English version was reviewed by the three psychiatrists who translated it. They modified some items to enhance their comprehensibility in consideration of Korean patients. A bilingual physician revised and compared the English version and the Korean version. Finally, the Korean version was revised by a Korean language expert, taking into account the cultural differences between languages. The questionnaire was finalized upon agreement from the three psychiatrists.

In addition to the original Singaporean survey questionnaire, we measured demographic data (e.g., age, sex) and clinical experience. Each group received a version designed for them.

Method

A contact list of psychiatrists and psychiatry trainees was obtained from a 2012 Annual Report by the Korean Neuropsychiatric Association. For convenient response, the survey was sent by e-mail to a random sample of psychiatrists. A total of 230 psychiatrists were in the psychiatrist group, including faculty members of university hospitals, psychiatrists in psychiatric hospitals or private clinics, and psychiatric trainees in training hospitals. To improve response rate, a second round of e-mails was sent one month after the initial email. The survey was conducted from April to June of 2013.

The patient questionnaires were collected with the cooperation of the staff of 10 training hospitals. Three hundred paper questionnaires were sent by mail to collaborating hospitals (30 per hospital). The questionnaires were provided to psychiatric patients in waiting rooms of outpatient clinics for voluntary participations. Completed survey were collected and sent back by mail. The patient survey was completed from April to July of 2013.

Statistical analysis

According to the Singaporean survey, the 40 items were grouped into four themes as a result of factor analysis (7) (Table 1). The four themes were: Professional, Relationship, Academic Executive, and Personal Values. Professional theme involved qualities relating to clinical practice (e.g. Awareness of boundary issues). Relationship theme involved qualities relating to working with other professionals (e.g. Able to bond with colleagues). Academic Executive theme involves qualities of academic pursue (e.g. Performing research, understand operational management). Personal Values are qualities relating to innate characteristics (e.g. Displays honesty/integrity).

Table 1

Items categorized into four themes with scores for each item

No.	Items	Psychiatrists		Patients
		Mean ± SD	Rank	Mean ± SD	Rank
	Professional
6	Is able to respond to constructive criticism	3.31 ± 0.74	14	3.21 ± 0.94	20
9	Possesses wisdom/common sense/judgment	3.44 ± 0.67	6	3.53 ± 0.78	7
13	Is a good communicator and listener	3.53 ± 0.63	4	3.7 ± 0.63	1
14	Has maturity / is stable	3.41 ± 0.69	8	3.44 ± 0.89	10
16	Is responsible	3.34 ± 0.65	13	3.47 ± 0.84	9
17	Is sensitive to gender, ethnicity and culture	3.23 ± 0.76	18	3.16 ± 1.06	25
19	Is aware of boundary issues	3.19 ± 0.78	19	3.16 ± 0.94	23
23	Respects students, staff, patients and carers	3.37 ± 0.7	9	3.49 ± 0.79	8
25	Discusses values and attitudes	2.97 ± 0.91	21	3.15 ± 0.88	27
27	Exhibits professionalism	3.35 ± 0.73	12	3.55 ± 0.66	6
28	Models good doctor-patient relationship	3.56 ± 0.61	3	3.64 ± 0.68	3
29	Accepts uncertainty	3.3 ± 0.75	15	3.21 ± 0.88	21
40	Is conscientious	3.36 ± 0.74	11	3.55 ± 0.79	5
	Personal values
7	Likes dealing with people/is personable	2.36 ± 1.02	38	2.96 ± 1.09	35
12	Has clinical competence	3.43 ± 0.73	7	3.38 ± 0.79	13
32	Provides effective explanations, answers, demonstrations	2.84 ± 0.87	28	3.22 ± 0.82	19
35	Emphasizes observation	3.59 ± 0.62	2	3.64 ± 0.63	4
36	Is compassionate	2.84 ± 0.95	27	2.93 ± 1.08	38
37	Displays honesty/integrity	3.37 ± 0.7	10	3.38 ± 0.83	12
38	Demonstrates patience	3.24 ± 0.74	17	3.41 ± 0.84	11
	Relationship
2	Is nurturing	2.97 ± 0.92	21	3.04 ± 1.07	32
3	Challenges junior staff, stretches their abilities, actively involves them	2.84 ± 0.99	30	3.2 ± 0.98	22
5	Creates an atmosphere within the team where individual opinions are valued and enjoy a sense of ownership of decisions	2.94 ± 0.88	23	3.32 ± 0.94	15
10	Is able to bond well with colleagues	2.69 ± 0.92	34	3.06 ± 1.02	30
11	Is a role model	2.85 ± 0.9	26	3.08 ± 0.95	29
20	Is able to motivate junior staff	2.62 ± 0.92	36	3.04 ± 1	31
21	Is willing to share personal insights with junior staff	2.84 ± 0.96	28	3.29 ± 0.9	16
24	Encourages junior staff participation	2.79 ± 0.86	32	2.96 ± 0.99	34
31	Is accessible to junior staff	2.72 ± 0.92	33	2.94 ± 0.98	36
34	Provides individual attention to junior staff	2.82 ± 0.88	31	3.16 ± 0.96	26
	Academic-executive
18	Has understanding of operational management	2.31 ± 1.07	39	2.33 ± 1.24	40
22	Is able to link basic science to clinical practice	2.9 ± 0.86	24	3.02 ± 0.96	33
26	Does research	2.28 ± 1.16	40	3.26 ± 0.98	17
30	Is scholarly	2.69 ± 0.96	34	2.94 ± 1.02	37
33	Is organized	2.86 ± 0.85	25	3.11 ± 0.92	28
	Others
1	Is experienced	3.47 ± 0.74	5	3.36 ± 0.89	14
4	Is humble	3.03 ± 0.99	20	3.16 ± 1.11	24
8	Respects confidentiality	3.66 ± 0.64	1	3.66 ± 0.77	2
15	Has resilience	3.28 ± 0.81	16	3.23 ± 0.93	18
39	Has good sense of humour	2.47 ± 0.99	37	2.84 ± 1.12	39

We hypothesized that there would be differences between the psychiatrist group and patient group. Comparisons between scores on each item and each theme were performed using t-tests. ANOVAs were performed to test for significant differences in the scores for individual qualities and themes between the two groups. Scheffé's test was used to rank the themes for each group. To compare the top and bottom 10 qualities, mean scores on each individual quality was ranked for each group. All analysis was completed using Predictive Analytics Software (SPSS PASW) Version 18.0 (SPSS, Chicago, IL, USA).

Ethics statement

The study protocol was approved by the institutional review board of Konkuk University Chungju Hospital (IRB No. 2013-017). Informed consent was waived by the IRB because participants in the survey study were voluntary.

RESULTS

The response rate was 60.9% (140 of 230) for psychiatrists and 61.3% (184 of 300) for patients. The basic characteristics of the respondents are summarized in Table 2.

Table 2

Respondents' baseline characteristics

Characteristics		No. (%)
		Psychiatrists (n = 140)	Patients (n = 184)
Sex	Male	94 (67)	86 (47)
	Female	46 (33)	98 (53)
Age (yr)	21-30	34 (24)	28 (15)
	31-40	53 (38)	55 (30)
	41-50	35 (25)	48 (26)
	51-60	17 (12)	34 (18)
	> 60	1 (1)	19 (11)
Working status (psychiatrists only)	Attending psychiatrist in a training hospital	46 (33)
	Psychiatrist in a general hospital	17 (12)
	Owner of a psychiatric clinic	7 (5)
	Resident	70 (50)
Experience as a psychiatrist (yr) (psychiatrists only)	< 5	15 (11)
	5-10	22 (16)
	11-20	39 (28)
	< 20	21 (15)
	Resident	70 (50)

Comparison of the total score and theme scores between the two groups

Both the patient group and the psychiatrist group ranked the themes in the following order: Professional > Personal Values > Relationship > cademic Executive. Although both groups ranked the themes in the same order, for all themes, the mean scores given by patients were higher than those given by psychiatrists (Table 3).

Table 3

Comparison of the total score and theme score between two groups

Parameters	Psychiatrist (n = 140)	Patient (n = 184)	t	P
Total score (Mean ± SD)	3.05 ± 0.53	3.31 ± 0.578	-4.628	< 0.001
Professional(Mean±SD)	3.33 ± 0.488	3.47 ± 0.578	-2.464	0.014*
Personal values (Mean ± SD)	3.09 ± 0.577	3.32 ± 0.624	-3.879	< 0.001
Relationship(Mean±SD)	2.81 ± 0.716	3.21 ± 0.687	-5.895	< 0.001
Academic executive (Mean ± SD)	2.61 ± 0.742	3.02 ± 0.741	-5.769	< 0.001
Theme ranking By Scheffé test F (P)	Psychiatrist	Professional > Personal values > Relationship, Academic executive
	30.745 (<0.001)
	Patient	Professional, Personal values > Academic executive; Professional > Relationship
	13.188 (<0.001)

*P<0.05.

Scheffé's test revealed that, in both groups, the Professional theme was ranked significantly higher than the Personal Values theme. There was no significant difference between Relationship theme and Academic Executive theme in the psychiatrist group. In the patient group, there was no significant difference between Professional theme and Personal Values theme. However, these two themes were ranked higher than Academic Executive theme. Overall, the ranking orders of themes in the two groups were the same. However, the patient group appeared to consider the Relationship theme as more important than the psychiatrist group.

Mean scores for all qualities were 3.05±0.530 for the psychiatrist group and 3.31±0.578 for the patient group. Based on t-test, the total scores of patients were significantly (P<0.001) higher than the total scores of psychiatrists. Comparisons for each theme revealed that the mean scores for each theme from the patient group were significantly (P<0.05) higher than those from the psychiatrist group (Table 3).

Ranking of individual qualities by average Likert score

Rankings of individual qualities by each group overlapped on many items, with rankings for some items varied quite considerably (Table 2). The item of "respects confidentiality" was ranked first by psychiatrists, but ranked second by patients. The top item for the patient group was the item of "is a good communicator and listener", which was ranked the fourth by the psychiatrist group. Both item of "respects confidentiality" and "is a good communicator and listener" were in the Professional theme, suggesting Professional theme was the most important one for both groups (Table 3).

The bottom ranked (40th) item for the patient group was the item of "has understanding of operational management", which was ranked 39th by the psychiatrist group, suggesting that an understanding of operational management was the least important quality of a psychiatrist considered by both groups.

Overall, 7 of the top 10 items overlapped in both groups, although the orders were somewhat different between the two groups (Table 4). In addition, 7 of the bottom 10 items overlapped in the two groups (Table 5), suggesting that the expected qualities for a good psychiatrist do not differ substantially between psychiatrists and patients.

Table 4

Top 10 items ranked by the two groups

Rank order	Psychiatrist group	Patient group
1	Respects confidentiality	Is a good communicator and listener
2	Emphasizes observation	Respects confidentiality
3	Models good doctor-patient relationship	Models good doctor-patient relationship
4	Is a good communicator and listener	Emphasizes observation
5	Is experienced	Is conscientious
6	Possesses wisdom/common sense/judgment	Exhibits professionalism
7	Has clinical competence	Possesses wisdom/common sense/judgment
8	Has maturity/is stable	Respects students, staff, patients and carers
9	Respects students, staff, patients and carers	Is responsible
10	Displays honesty/integrity	Has maturity/is stable

Bolded items overlap across the two groups.

Table 5

Bottom 10 items ranked by the two groups

Rank order	Psychiatrist group	Patient group
31	Provides individual attention to junior staff	Is able to motivate junior staff
32	Encourages junior staff participation	Is nurturing
33	Is accessible to junior staff	Is able to link basic science to clinical practice
34	Is scholarly	Encourages junior staff participation
35	Is able to bond well with colleagues	Likes dealing with people/is personable
36	Is able to motivate junior staff	Is accessible to junior staff
37	Has good sense of humour	Is scholarly
38	Likes dealing with people/is personable	Is compassionate
39	Has understanding of operational management	Has good sense of humour
40	Does research	Has understanding of operational management

Bolded items overlap across the two groups.

DISCUSSION

Society will always expect good doctors. However, the definition of "a good doctor" changes over time. Since Hippocrates first defined "a good doctor" in 400 BC with the Hippocratic Oath (8), the definition has been modified based on changes to society's expectations. Similarly, what constitutes a good psychiatrist has changed over the years.

Around two to three decades ago, the role of psychiatrist was much more ambiguous than what it is now. In the past, people had a lack of understanding of psychiatric diseases. At that time, in Western countries, a good psychiatrist was defined as "a good community psychiatrist", "super-chairman" or "all purpose psychiatrist". Psychiatrist in the past was required to fulfill both administrative and executive roles (9). Over time, the definition has evolved to have emphasis on professional skills (e.g., consultation liaison, psychopharmacology) in the USA (1).

In contrast to Western countries, a relatively strong stigma has been associated with psychiatry and mental illnesses in Asian countries, including Korea. This has been a barrier to mental health services (10). During the last decade, suicide rate of Korea has rapidly increased, becoming a major social issue (11). In light of this phenomenon, social and public interest in mental health has increased. Government activities and other efforts (e.g., the media's focus on mental health care, investment in social services and programs for mental health) have reduced this stigma. Subsequently, demand and interest in psychiatric services has increased (11, 12). However, few studies or systemic research were focused on what constitutes "a good psychiatrist", which was in the context of a relatively low interest in and a negative attitude towards mental health. With the recent changes in attitudes toward mental health, psychiatric research (e.g., National study for suicide prevention, a research of PTSD patients of a disaster) is expected to increase. The objective of this study was to identify the qualities that are required for a good psychiatrist and to help improve the training of future psychiatrists.

A previous study showed that clinical ability (e.g., accurate diagnosis and treatment) is regarded as the most important quality of a "good doctor" in Korea (13). Studies in other countries reported that the public regarded clinical capability (e.g., knowledgeable, keeping up-to-date) as the most important quality, whereas physicians regarded the moral-ethical domain (e.g., "honest" and "responsible and trustworthy") as the most important qualities (14). A similar study of the general public showed that both cognitive and interpersonal characteristics were considered essential to make a good doctor (15). In consistent with those earlier studies, our results also identified professional character as integral to being a good doctor. Both psychiatrists and patients ranked the Professional theme as the most important one for a good psychiatrist, suggesting that a good psychiatrist is required to be a good doctor as a member of the medical profession in Korea.

Patients responded that both personal values and professional values were important in a good psychiatrist. Good communication skills, respect for confidentiality, and the ability to model the doctor-patient relationship were seen as the most important in the professional values mentioned. Patients also believed generosity, compassion, a sincere attitude, and the understanding of the patient's mind were also important, from the qualitative component of the study. This would appear to underscore patients' belief that the therapeutic interaction between psychiatrist and patient itself is critical, in addition to clinical knowledge and more technically defined skill sets. The high cultural stigma against mental illness in Korea may also contribute to the need for a strong therapeutic relationship as part of the healing process. This has implications for training and further research.

Patients gave more scores to the Relationship theme than psychiatrists did, supporting the idea that patients consider doctor-patient relationships to be more important than academic ability. This finding differed from findings from previous studies in other countries for general physicians (14), suggesting a higher expectation regarding doctor-patient relationships and communication skills for psychiatrists compared to general physicians. In support of our finding, a similar result was reported in another study performed in another country (16).

Patients ranked "is a good communicator and listener" the highest, which was categorized under the Professional theme in the original questionnaire (7). In Korea, this quality could be categorized under the Relationship theme considering the cultural atmosphere and people's emotions toward this phenomenon. Patients' reference to relationships in their subjective answers supports the validity of this re-categorization.

Overall, patients rated both interpersonal skills and professional aspects highly. In addition, the patient group considered interpersonal skills more important for a good psychiatrist than the psychiatrist group. Similar results were found by a systematic review by the European Task Force on Patient Evaluations of General Practice (EUROPEP) (17).

Psychiatrists considered Relationship theme to be less important than Academic Executive theme (Table 3). The difference in mean scores for Relationship theme between groups was notable (Table 3). In light of this result, psychiatric resident training programs should be more focused on raising good psychiatrists based on patient values by emphasizing the development of interpersonal skills as well as academic ability. Across all themes, patients' mean score was significantly higher than that of psychiatrists. This indicated that patients' expectations were generally higher than psychiatrists' on most of the qualities (Table 3). The previous study (18) conducted in Singapore also showed that the patient group had higher expectation for a good psychiatrist than the psychiatrist group, suggesting that psychiatrists and patients have different standards when evaluating "a good psychiatrist." When comparing the ranks of all items, most of the top and bottom 10 items overlapped in the two groups. Four of the top five items overlapped, indicating that both groups expected similar values for "a good psychiatrist" (Tables 4, 5). Although our results suggested that Korean patients and psychiatrists had similar views about what a good psychiatrist should be, the study in Singapore (18) found that patients and psychiatrists had clearly different view for "a good psychiatrist". This could reflect a very good social contract or shared understanding of psychiatry's role in Korean. However, further studies in other countries are needed to confirm such theory.

Some difference in values should be considered in clinical practice to help improve doctor-patient communication. Interestingly, Academic Executive theme appeared to be the least important theme for both groups. Both psychiatrists and patients agreed that psychiatrists should have a basic level of medical knowledge. In general, the public is aware of the strict curriculum standards of medical schools in Korea, therefore assuming knowledge competency of doctors and psychiatrists upon completion. A previous study found similar results that patients were relatively less concerned with clinical ability (8). Furthermore, psychiatric treatment may influence patients to score more for the Personal Values and Relationship themes than for the Academic Executive theme.

Overall, compared to previous studies on "good doctors," both patient and psychiatrist groups had similar quality expectations for a "good psychiatrist". When evaluating a "good psychiatrist" based on themes, Professional and Relationship themes were more important than the other two themes.

The results of the present study should be interpreted in light of the study's limitations. Firstly, the sample size was small and the response rate was not high. Therefore, it may be difficult to generalize our results. Secondly, although the Korean questionnaire was carefully revised by several specialists, there may be gaps in meaning between the original version and the Korean versions. Further, the Korean version used the same themes extracted from Singaporean version's factor analysis. These themes may not be represented in exactly the same way as the original after the translations. To compensate for this possible difference, an English version of the original questionnaire was also provided. However, there still might be possibility of cultural differences in the interpretation of each item. In light of these limitations, the implication for this study is that it serves as a preliminary study on the definition of a good psychiatrist in Korea.

In summary, we conclude that a good psychiatrist in Korea is defined as "a good communicator and listener with a professional manner, who respects confidentiality and has good doctor-patient relationships." This study will provide a guide for future studies on the qualities of psychiatrists in a more detailed and systematic way. Moreover, based on the results of this study, psychiatric resident training programs could be improved with consideration of the qualities identified for good psychiatric practice. Further studies should broaden the sample subjects beyond patients to include the general population. Furthermore, investigation on qualities of doctors in other specialties would identify qualities that are unique to the profession of psychiatry. Our future work will include comparison among countries to provide a basis for understanding the cultural differences in the field of psychiatry.