Attitudes to psychiatry: a comparison of Spanish and US medical students.

There is a growing concern in many countries over the low recruitment into psychiatry among medical graduates. This has led to studies that aim: (1) to study the attitudes of medical students towards psychiatry, (2) to determine factors that influence such attitudes, (3) to assess the possible causes of this low recruitment and (4) to try to change students' views of psychiatry during their medical education to improve recruitment.

The present tendency in daily practice towards managed care has changed psychiatric training, and now students may consider psychiatrists as mere psychopharmacologists.

In the United States a negative attitude towards psychiatry or the psychiatrist’s role has been observed among medical students at the start of their freshman year (Feifel et al, 1999); however, on completion of their psychiatric training it seems that the opinions of students are now improving (Balon et al, 1999) in comparison with attitudes that were prevalent 25 years ago (Nielsen & Eaton, 1981).

Over the past 20 years studies in the United States (Nielsen & Eaton, 1981; Balon et al, 1999; Sierles et al, 2003,) and in the United Kingdom (Brockington & Mumford, 2002) have reported that the percentage of students choosing psychiatry as their future specialty has decreased steadily, although other evidence suggests a small increase recently among US students, from 3.5% in 1999 to 4.5% in 2003 (National Resident Matching Program, 2003). The recent increase may be due to a change in opinions towards the field, although this may represent only a partial explanation (Balon et al, 1999).

Factors that affect the proportion of students contemplating a career in psychiatry have been divided into extrinsic (e.g. national trends, geographical region) and intrinsic factors (e.g. the quality of psychiatric education). In the USA it seems that local and regional extrinsic factors were not associated with an increase in the proportion of students choosing psychiatry (Sierles et al, 2003). This emphasises that the quality of educational programmes could be one of the most important influences on students’ attitudes to psychiatry. Experiences such as students’ contact with psychiatric patients (Singh et al, 1998), the quality of training (Lee et al, 1995) and the prestige of the local psychiatric department (Sierles, 1982) emerge as influential aspects of psychiatric education. Sierles et al (2003) have discussed concerns about future recruitment into the psychiatric profession in the United States. One of these concerns is the graduating seniors’ suboptimal satisfaction with their psychiatry clerkships. Another is that clerkship directors in psychiatry, when compared with those in other specialties, tend to perceive more that managed care reduces the quality of clinical medical education. The present tendency in daily practice towards managed care has changed psychiatric training, and now students may consider psychiatrists as mere psychopharmacologists. Thus the profession may not fulfil students’ expectations that psychiatry would be more oriented towards psychotherapy (Balon et al, 1999).

Attitudes to psychiatry

In order to gain a broader view of the process of recruitment, we compared the attitudes to psychiatry of Spanish and US medical students (Pailhez et al, 2005). We chose these groups because a comparison between two different countries with different teaching approaches to psychiatry could help us gain a broader perspective on the complex process of recruitment. We recorded the opinions of 151 students who had completed psychiatry at the end of their fourth year. Our survey was based on responses to a 33-item questionnaire, using a cross-sectional design. Data on US students were obtained from the study by Balon et al (1999), whose questionnaire explored the attitudes of medical students towards psychiatry in six areas: (1) overall merits of psychiatry, (2) efficacy, (3) role definition and functioning of psychiatrists, (4) possible abuse and social criticism, (5) career and personal reward and (6) factors specific to the medical school.

We found that many Spanish students felt that psychiatry was not an expanding frontier of medicine. However, Spanish students regarded psychiatry as more scientific and precise than other specialties (72.9% of the Spanish sample endorsed this view, compared with 56.1% of the US sample).

More Spanish than US students agreed that a psychiatric consultation could be useful for medical or surgical patients. However, about a third of Spanish students (37.1%) said that most psychiatrists are not logical thinkers, compared with 17.9% of the US sample. Furthermore, the Spanish students were largely of the opinion that psychiatrists have no more authority and influence than other mental health professionals; that they are too apologetic when teaching psychiatry; and that psychiatrists abuse their legal power to hospitalise patients against their will. Finally, Spanish students expressed a greater preference than did US students for a style of psychiatric practice that was both more biological and more attentive to the patient’s psychological problems.

Regarding career choice, Spanish students tended to believe that psychiatry has low social prestige. However, they seemed to be subject to fewer additional external pressures when making their choice of specialty than were students in the United States; these pressures included the opinion of their family (14.9% in Spain versus 25.3% in the United States), friends (20.4% in Spain versus 33.0% in the United States) and fellow students (34.0% in Spain versus 41.5% in the United States).

Spanish students had a worse opinion of the quality of psychiatry teaching (48.3% of students in Spain believed it to be good, compared with 73.8% in the United States). (These questions referred to both the quality of the theoretical lessons and the psychiatry rotation.) They also described receiving less encouragement to enter psychiatry as a profession than did students in the United States (49.6% in Spain versus 69.1% in the United States), but reported more respect for psychiatry among non-psychiatric staff (71.7% in Spain versus 54.5% in the United States).

Recruitment

In general, Spanish students’ views of psychiatry were positive, as were those of the US students in the study by Balon et al (1999). However, comparisons revealed differences in responses to some questions relating to the bio-psychosocial concept of illness, salary, social pressure and respect from non-psychiatric staff. The number of students choosing psychiatry as their future career was 6% in our study. This percentage is higher than the 4.5% currently reported in the United States.

Some US authors have tried to elucidate the possible causes of low recruitment: first, there is a large influence of biological psychiatry in the specialty nowadays; second, there are lower income prospects compared with other specialties; third, psychiatry, psychology, social work and primary care medicine overlap in the treatment of patients (Sierles & Taylor, 1995; Balon et al, 1999). Other causes of negative attitudes could be the negative social pressure exerted by colleagues and non-psychiatric staff in the medical schools (Nielsen & Eaton, 1981), or the inability of psychiatry to change society through medicine (Balon et al, 1999). Approximately 14% more Spanish students than US students felt that psychiatry is too biological (32.6% in Spain versus 18.5% in the United States) and that, on average, psychiatrists make as much money as most other doctors (62.4% in Spain versus 48.7% in the United States). More believed that their friends (66.0% in Spain versus 58.4% in the United States) and non-psychiatric staff (71.7% in Spain versus 54.5% in the United States) would respect their decision to become a psychiatrist. These factors affect recruitment in a very complex way, and the explanations of the difference in attitudes of Spanish and US students are speculative. In the United States students do not seem to have the same reasons as Spanish students for negative attitudes to psychiatry in these specific respects.

Spanish students were largely of the opinion that psychiatrists have no more authority and influence than other mental health professionals; that they are too apologetic when teaching psychiatry; and that psychiatrists abuse their legal power to hospitalise patients against their will.

The uptake of a residency position in Spain is determined by an official examination; the overall number of positions is determined by the Ministry of Health. Only those students who complete the 4 years of residency after the entrance examination get the specialist degree. Over the last decade, the Ministry of Health has increased the number of psychiatry positions by 33%. In the year 2002/03, out of a total of 5496 medical residency positions, 2.9% were in psychiatry, making it the eighth most available specialty. Despite this increase in the number of positions, 51.7% of the students from our study with an interest in psychiatry after their fourth year of medical school could not enter the specialty.

In this respect, the recruitment process has not presented particular difficulties for the training of psychiatrists in Spain. The number of positions offered yearly by the Ministry of Health depends on the capacity of the accredited training centres, the national budget available and social demand. Therefore, in contrast with US students, who are guaranteed a psychiatry position, Spanish medical students may regard psychiatry as a more worthwhile specialty because of the competition for training places.

From the 1950s to the mid-1970s, studies in the United States showed that students considered psychiatry more unscientific and imprecise and to have less prestige than nowadays. However, recruitment then was at its highest (Castelnuovo-Tedesco, 1967; Zimet & Held, 1975). Students seemed to make their choice while being very aware of the specialty’s weak points. Paradoxically, when students’ opinions are more critical, recruitment in both Spain and the United States seems to rise, probably because being more critical leads to a better understanding and stronger desire to choose the specialty. Or could it be that recruitment has nothing to do with attitudes to psychiatry after all?

Paradoxically, when students’ opinions are more critical, recruitment in both Spain and the United States seems to rise, probably because being more critical leads to a better understanding and stronger desire to choose the specialty.