You must be out of your mind

Have you thought about psychiatry for a career? Shikha Singh thinks it's crazy that so many medical students have not

Walking into firms on the first day of my penultimate year and psychiatry was my first rotation. After four weeks of lazy summer days, enduring the London rush hour to arrive at a hospital in the middle of nowhere carried a tantalising sense of personal achievement. As I walked down the discreetly named ward, the sight around me did little to allay my ignorant concerns about psychiatry. Add to this the fact that I was now being told to spend an hour taking a history, and I was just about ready to give up on psychiatry before it had even begun.

Scanning the rest of my group, I gave a look of bemusement that could in no way have predicted how fascinating I would find this complex subject. Why, then, am I in such a minority? In 2004, the Royal College of Psychiatrists found that only 3% of medical students opt to pursue psychiatry as a career. This clearly rings alarm bells with regard to the future recruitment of psychiatrists.^w1

A study published in 1999 alarmingly found that a quarter of new medical students had already ruled out psychiatry as a potential career choice, reiterating the argument that psychiatry has an image problem.^w2 Is a full revamp long overdue?

Even the cynics among you will have to master psychiatry. Let's not forget that aspiring general practitioners will spend a significant proportion of their time managing psychiatric illness, not to mention the fact that disorders of the mind may manifest in any field of medicine.

The problem of waning interest of medical students in psychiatry is not confined by culture or geography, having been identified in countries as diverse as India, Saudi Arabia, Germany, the United States, Hong Kong, Israel, Chile, Australia, Malaysia, and Nigeria.^w2-w14 But the only way to tackle the problem is to understand the reasons why psychiatry is considered so undesirable.

It's not scientific?

Psychiatry is often quoted as being boring and unscientific.^{w1 w11 w15} Many students feel that psychiatry does not pay homage to the knowledge and skills that they have spent years acquiring. After all, what was the point of perfecting your suturing and memorising the microvascular complications of type 2 diabetes mellitus if all you will spend your life doing is listening to people's feelings. A course mate once told me, "You don't need to be a doctor to do it anyone can sit there and talk to somebody about their upbringing. There's no medicine in it."

But, is it right to perceive a psychiatrist's role this way? Ultimately, whatever your specialty, you will be listening to people's problems, and, yes, psychiatrists do the same. But they extrapolate that information and use their unique skills to take an appropriate history, do a mental state examination, diagnose from complex differentials, and then formulate a multidisciplinary management plan from a multitude of treatments. Psychiatrists have additional responsibilities in liaising with the police, lawyers, and patients' families.

Although psychiatric pathology can be intangible, that does not equate to being unscientific.^w1 Psychiatry includes an extensive range of specialist interests, including old age psychiatry, alcohol and substance misuse, eating disorders, child and adolescent psychiatry, liaison psychiatry, puerperal disorders, and forensic psychiatry, many of which overlap with other medical fields.

It lacks excitement?

Confession time: how many of you used to watch ER and imagine yourselves white coat clad and stethoscope bearing, one day rushing around a hospital like County General, defibrillating the dying patient in trauma room 1? Medical students often savour the idea of the glamour that they anticipate medicine will comprise. Some are inspired by cutting edge surgical advances; others may yearn to be the next Karl Kennedy from Neighbours.

But where is the thrill in sitting in a quiet room for an hour, forcing conversation out of your patient? Unfortunately, psychiatry has a reputation for being rather sluggish and uninspiring. The answer does not lie in sensationalising it, but if it could be portrayed as the topical intellectually stimulating subject that it is, its allure may be restored.

It's depressing?

As most medical students have recited at some stage, one of the reasons we chose this vocation is because we desired a rewarding career that would allow us to help people. A widespread perception is that psychiatry is a disturbing area of medicine, in which most patients do not recover and are ungrateful. This was not helped by the fact that a consultant psychiatrist once told me that this was not the specialty to choose if you wanted presents from patients.

Firstly, although some psychiatric patients may not be of a disposition that facilitates overt expression of gratitude, it does not mean that they do not feel it. Secondly, as doctors, we should desire to see an improvement in our patients more than recognition for our contribution. Therefore, if you have improved the life of a mother who had depressive disorder so that she can better manage her family or a patient with schizophrenia, who is subsequently able to maintain a job, then this field of medicine will be as rewarding as any other.

Psychiatric illness is stigmatised

Before I started psychiatry, the topic of stigmatisation had arisen repeatedly in ethics and psychiatry lectures. I was therefore disheartened that informed medical students were taking comprehensive histories from patients only to leave the room and make derogatory comments, reflecting their own stigma towards mental illness. Worryingly, one study found that this stigma is "perceived to continue throughout the medical profession."^w16 Such barriers may prevent medical students from being able to empathise and reduce their urge to improve patients' lives. Compare this with specialties such as oncology, for example, about which medical students may feel a more instinctive desire to help patients. But mentally unwell patients generally have little control over their condition either, and we should not dismiss the patients most worthy of our care.

Any uninformed perceptions I may have had about mental illness were quickly dispelled during my attachment. I once saw an extremely intelligent patient with psychotic symptoms, who was overtly expressing violent intent. I was astounded to see that, after just a few weeks of sustained inpatient antipsychotic therapy, all such thoughts had disappeared, and, even when prompted, he failed to show any violent feelings. This patient clearly had an illness, presenting with particular symptoms (violent thoughts) and after appropriate therapy, they disappeared, restoring his health to almost premorbid levels. Thus, it becomes apparent that psychiatric illness is not worlds apart from other medical illnesses.

Stereotyping doesn't help

Here are a few sound bites from the array of stereotypes that exist regarding psychiatry: "Takes one to know one." "Do it long enough and you'll turn into one." "The fact that they retire earlier speaks volumes."

Unfortunately, these old fashioned whims still repel students from careers in psychiatry. Although it is understandable that students consider this specialty to be among the most stressful, it is by no means the case that psychiatrists are more likely to go mad. I was pleasantly surprised by the enthusiasm that the psychiatrists on my attachment showed towards their careers and the jovial manner in which the team interacted.

Psychiatry is also commonly misconstrued a dangerous specialty, and many students harbour fears of getting stalked or stabbed. Statistically, this is less common than students think. A study done in a psychiatric intensive care unit found that only 3% of admitted cases displayed any violence.^w17 A rotation in an emergency department, for example, would subject you to a more threatening environment. Psychiatrists also receive training and become more experienced at dealing with aggressive patients. One of the Royal College of Psychiatrists' learning objectives for senior house officers working in addiction psychiatry is that they should have "knowledge of local procedures for dealing with violent episodes."^w18

Another factor that worries medical students is the assumption that essentially all patients will be criminals. Most mentally unwell patients are not, but whichever branch of medicine you select, you will inevitably have to deal with people from all walks of life, and you must be able to maintain a professional and non-judgmental attitude towards them.

Professional snobbery

Although surgeons seem to look down on physicians and physicians on surgeons, everyone seems to look down on psychiatrists. It's sad but true: several studies have identified the perception that psychiatry lacks "prestige among the medical community," and the thought of being looked down upon by their counterparts is turning away medical students.^{w11 w19}

I will never forget the look on the face of an oncology registrar when I told him that I would keep psychiatry on my list of options as a potential career choice. Rather sceptically, I had to ask myself whether I would have got the same response if I had said I wanted to specialise in surgery or general practice, for example. It is exactly these types of views that have been a barrier to interest in the field for many years.^w20

Understandably, everybody wants to feel respected by their colleagues, but psychiatry is no less medical than other fields. In my opinion, there is no such thing as the quintessential medical specialty.

MAURO FERMARIELLO/SPL
Hey Doc, are you out of your mind too?

Poor undergraduate teaching

Finally, poor undergraduate teaching may be held accountable for failing to captivate students. Common sense dictates that if you hate the attachment, and nobody involves you, you are unlikely to want to specialise in that area. From a personal point of view, I can say that the reason I enjoyed psychiatry so much, when many of my student colleagues loathed it, was largely attributable to the enthusiasm of the team I was attached to, a finding that has also been verified in the literature.^w21

Undergraduate teaching could serve to influence, and teams within teaching institutions should endeavour to stimulate students. This is particularly important for psychiatry, a specialty shrouded in concerns about recruitment and retention. Attitudes towards psychiatry seem to improve transiently after the undergraduate attachment but fade over the next few years.^{w10 w22 w24}

The mode of teaching may also have a part to play, and it has been proposed that undergraduate psychiatric education needs a "radical" transformation.^w3 Perhaps a move away from didactic teaching towards problem based approaches may be a solution.^{w4 w25} Regardless of their impact on students' attitudes, however, educational improvements and undergraduate attachments have not been found to make a difference to the number of graduates choosing psychiatry.^{w3 w22} This suggests that the other factors that come into play are stronger determinants of a medical student's choice to pursue psychiatry, or not, which is more often the case.

Making a difference

The prevalence of mental illness is increasing.^w21 The number of psychiatrists is decreasing. Suffice to say that if nothing is done to reduce this discrepancy, mental health services will have a crisis on their hands in the future. The problem of why medical students opt out of psychiatry is multifaceted, however, and to amend the situation demands systematically and aggressively resolving each factor. Initiative needs to be taken to tackle the difficult and engrained problem of stigma and lack of awareness; to change age old cultures within medicine that demean psychiatry; and, in addition to that, to instigate and maintain motivating clinical attachments. Psychiatrists make a real difference to the lives of mentally unwell patients and their families, and, ultimately, that is the reason most of us chose to pursue a career in medicine.

References ^w1-w25 are at studentbmj.com.

Competing Interests: None declared.

Shikha Singh, fifth year medical student, Imperial College,
London
Email: shikha.singh@imperial.ac.uk


studentBMJ 2006;14:309-352 September ISSN 0966-6494