The making of a psychiatrist: an Israeli perspective.

When medical school educators - polished veteran doctors - review data on their students' attitudes towards residencies, they remember their own long days in the anatomy dissection room. They recall treating their first teenage patient and comforting a patient seeking solace while succumbing to a fatal illness. They think about why they made their important career choice. Thus the glory days of medical school become a defining and shaping experience for physicians, similar to boot camp for veteran paratroopers.

While cultures differ, medical education seems to differ less, as all doctors have to examine, diagnose and treat. Within this context, the popularity of specific specialties may be based on several factors with local influences. There have been efforts in recent years to quantify the attitudes of medical students using standard questionnaires (Nielsen & Eaton, 1981; Burra et al, 1982; Feifel et al, 1999). Below we describe the profile of the potential psychiatrist among Israeli medical students and compare our results with the findings of studies using similar research methods from Western countries with different traditions of psychiatry and medical education.

Is there no balm in Gilead; is there no physician there? (Jeremiah, 8.22)

Medical education in Israel

In Israel there are four medical schools. Approximately 300 medical students are accepted a year. Medical education is heavily subsidised by the government, so the total number of medical students is regulated. Many of those who are not accepted locally choose to study abroad. Those fortunate enough to be accepted in Israel are 2–3 years older on average than their counterparts in the United States, since most men and some women at the age of 18 are drafted into military service. Upon their discharge they are eager to start their schooling and make up for time lost. They then embark on a rigorous 6-year journey of intensive studies: 3 years preclinical and the remainder rotating clerkships through medical and surgical departments, including a 5-week clinical rotation in psychiatry during the fifth year. Upon completing their formal education they must pass state board examinations and then do a year of internship so as to qualify for a medical licence before starting a residency.

The increase in the percentage of female medical students and doctors is worth noting: 30.2% of all new licences in 1989 were issued to female doctors; that figure grew to 48.6% in 2003 (Israel Ministry of Health Statistics, 2003).

The results showed that psychiatry is as attractive as gynaecology and internal medicine, more attractive than family medicine, and less attractive than surgery and paediatrics.

Residency and psychiatric residency in Israel

As a young struggling nation, Israel took pride in its early years in investing energy to build the state and to take positive action in dealing with problems such as the absorption of new immigrants and fighting disease. Acknowledgement of personal difficulties and open discussion of emotions were frowned upon. Thus, psychiatry began to receive recognition only after the ‘basic needs’ of the country were met. This may account for the fact that a residency in psychiatry in Israel was not considered desirable 25 years ago, to such a degree that a non-governmental, philanthropic agency set up a fund to finance a special pool of psychiatric residencies.

An important contribution to Israeli psychiatry during those years was made by immigrant psychiatrists from Latin America with a traditional psychoanalytic orientation, many of whom still hold senior positions in the academic and clinical world.

However, things have changed in the course of the past 15 years. Close to a million immigrants arrived in Israel from the former USSR during the 1990s, including medical students, doctors and psychiatrists. Between 1989 and 1996, 10 070 licences to practise medicine were issued, two-thirds of which went to graduates of medical schools in the former Soviet Union. In 2003 the Ministry of Health issued 734 medical licences, of which only 38% went to doctors who had studied in Israeli medical schools (Fig. 1). Immigration has changed the profile of the Israeli psychiatrist, so that any survey of the attitudes of Israeli-trained medical students must take into account the fact that they do not necessarily represent a majority in many residency programmes (Bitterman & Shalev, 2005).

Fig. 1

Number of licences issued in Israel, 2003, according to location of doctors’ medical studies (total n = 734).

Whereas psychiatry received the highest score for ‘intellectually challenging’ of any residency … it received low scores for ‘the degree to which patients are helped’.

Attitudes and career preferences among Israeli-trained medical students

Our objective was to gain a better understanding of the attitudes and career preferences of Israeli medical students and to compare the results with research from the USA and Australia that had used similar methods (Abramowitz & Bentov-Gofrit, 2005). It was also our intention to gain insight into the learning process from the students’ perspective. To achieve these goals, a 23-item questionnaire was administered anonymously to 181 Israeli medical students in their preclinical years at the medical school of the Hebrew University in Jerusalem. The study population consisted of students in three consecutive preclinical years. The response rate was 70%. The results were analysed to find whether there were any statistically significant differences between students who considered psychiatry as a ‘chosen’ career or a ‘strong possibility’ for their career and those who did not.

Demographic analysis showed one significant difference between students who considered psychiatry residency and those who did not: students who considered psychiatry were all Jewish, although 7% of the responders were non-Jewish (P = 0.011). It is worth noting that roughly 10% of the medical student population in Jerusalem is Arab.

The results showed that psychiatry is as attractive as gynaecology and internal medicine, more attractive than family medicine, and less attractive than surgery and paediatrics.

When examining the aspects most important to medical students in their future career, they responded in favour of ‘intellectually challenging’ and ‘the degree to which patients are helped’ – results similar to American and Australian studies using the same questionnaire (Feifel et al, 1999; Malhi et al, 2002). Whereas psychiatry received the highest score for ‘intellectually challenging’ of any residency in Israel and Australia, it received low scores for ‘the degree to which patients are helped’ in all three countries.

Compared with the studies in the USA and Australia, the results of our study showed that more students considered psychiatry as an option, and fewer students disliked the field. The Israeli study also showed that 32.8% of local medical students in the preclinical years considered residency in psychiatry, compared with only 7.7% in the US and 15.9% in Australia (Fig. 2).

Fig. 2

Comparison of the popularity of a psychiatric residency between Israeli (n = 181), Australian (n = 655) and North American medical students (n = 223). Total ‘interested’ in psychiatry is the sum of the percentages who had ‘chosen’ psychiatry as a career and those who gave it as a ‘strong possibility’.

Why is psychiatric training more attractive to Israeli medical students?

In comparison with European countries, the ratio of psychiatrists per 100 000 population in Israel is favourable, at 13.7 (see Fig. 3). Perhaps it has to do with the long tradition of psychiatry as a ‘Jewish’ profession. This may be a myth, but none the less in our study no non-Jewish students preferred psychiatry. This raises the possibility that the greater appeal of psychiatry among the Israeli sample has to do with the compatibility of the perceived nature of psychiatric practice and the collective Jewish ethos (e.g. a tradition of valuing ‘cerebral’ pursuits).

Fig. 3

Number of psychiatrists per 100 000 population in different European countries. Data from Mental Health Atlas 2005: A Project of the Department of Mental Health and Substance Abuse, Geneva: World Health Organization. See http://cvdinfobase.ca/mh-atlas/index.htm.

It would seem that the apparent popularity of psychiatry in the preclinical years among Israeli students has much to do with local and cultural factors, including those referred to by Sierles et al (2003) as ‘extrinsic’ factors (e.g. national trends and the average age of the preclinical student).

Finally, the aforementioned increasing number of female graduates may account for some of the popularity of psychiatry, as they tend to give high ratings for the importance of ‘controllable lifestyle’ (less time-consuming schedule, the option of private practice, etc.).

Despite the relatively high percentage of preclinical medical students who consider psychiatry as an option, only approximately 6% eventually enter residency in the field (Israel Ministry of Health Statistics, 2003). Where do we lose those students? Are we allowing the ‘good’ ones to get away, to fields such as neurology and brain science on the one hand or to family practice on the other? Our research group is presently involved in a cohort study of students, following them through the clinical years and through the rotation in psychiatry. Preliminary results show that in the clinical years there is a dramatic fall in the popularity of psychiatry.

Despite the relatively high percentage of preclinical medical students who consider psychiatry as an option, only approximately 6% eventually enter residency in the field…. Where do we lose those students?

Conclusions

We began by asking whether the local Israeli population of medical students has anything in common with students abroad. It would seem that psychiatry has a universal image problem among students, who see it as an intellectually stimulating and interesting residency but devoid of any real potential to improve patients’ lives. This can be seen as an encouraging finding, as such problems can be remedied. Role modelling, academic promotion of psychiatrists, exposing students to successful treatment outcomes and an admissions policy open to excellence in the humanities are steps that can be taken to improve this image (Weissman et al, 1994).

In summary, do we expect the familiar image of the empathic and wise psychiatrist, though at times perhaps neurotic or eccentric – described by Zimny & Sata (1986) and others some 20 years ago – to fade away and make room for a more ‘hi-tech’, goal-oriented professional? Which prototype attracts the better students?

It would seem that psychiatry has a universal image problem among students, who see it as an intellectually stimulating and interesting residency but devoid of any real potential to improve patients’ lives.

Our view, based on the recent research in Israel and elsewhere, is that modern psychiatry is arguably the only specialty in which students feel that they can combine the two prototypes. It would seem that future psychiatrists will intuitively seek the experience of wholeness and integration in treating patients and favourably respond to being taught in this fashion. Perhaps in this respect our students may have much in common with students in many countries worldwide.