Medical student observations on a career

in psychiatry

Tessa Wigney, Gordon Parker

Objective: Interest in training in psychiatry appears to be in decline. To pursue reasons

why a career in psychiatry is not regarded as an attractive option for trainees, attitudes of
senior Australian medical students were surveyed.
Method: Fifty five medical students from one university were set a question inviting them
to detail reasons why doctors might be less likely to train in psychiatry as part of their
written examination in psychiatry. Several major themes and salient statements were
identified from a qualitative analysis.
Results: Analysis identified several multifaceted factors, including a difficult and
pressured work environment and lack of resources due to chronic underfunding;
perceived deficiency of personal skills, such as empathy; inadequate income; negative
implications of stigma, low prestige, and limited patient gratitude and job satisfaction.
These issues, coupled with the widespread belief that the discipline is unscientific and not
‘‘real medicine’’, may contribute to later decisions not to pursue training in psychiatry.
Conclusions: While the framing of the research question was biased towards eliciting
negative evaluations of a career in psychiatry, the responses are nonetheless instructive in
helping to understand the reasons why potential trainees might be discouraged from the
field. If psychiatry is to attract high-quality recruits, there is clearly a need to address
stigmatizing attitudes within the medical hierarchy, and provide positive educational
experiences for medical students that excite their imagination about a career or even a
calling
as against its negative ‘job’ status.
Key words: psychiatry, career, psychiatrists, medical students.

Australian and New Zealand Journal of Psychiatry 2007; 41:726 731

Over recent years it would appear that fewer junior
doctors apply for training in psychiatry, while those
who take up training are more likely to report
demoralization and to cease such training. While
many psychiatrists would be readily able to offer
multiple reasons for dissatisfaction with a career in
psychiatry, it appeared useful to obtain the view of
Gordon Parker, Scientia Professor, School of Psychiatry, University of
New South Wales and Executive Director, Black Dog Institute
(Correspondence); and Tessa Wigney, PhD student, School of
Psychiatry, University of New South Wales.
Black Dog Institute, Prince of Wales Hospital, Randwick, NSW 2031,
Australia. Email: g.parker@unsw.edu.au
Received 12 June 2007; accepted 13 June 2007.
informed observers of the psychiatric system
albeit
with a distinct focus on the public psychiatric sector.
Method
To that end, as part of their Year 5 written examination for the
University of New South Wales (UNSW) School of Psychiatry,
55 medical students were set the following open-ended question:
‘‘On the basis of your clinical experience, consider why doctors
might be less likely to train in psychiatry these days than
previously’’, along with nine other questions in a 2 h examination.
Answers were collated and qualitatively and quantitatively ana-
lysed.
All students had completed a 10 week term in psychiatry, and
been allocated for much of their training to one of seven general

# 2007 The Royal Australian and New Zealand College of Psychiatrists

Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
 T. WIGNEY, G. PARKER
hospital units, with most having some exposure to community
psychiatric teams and some having limited exposure to private
psychiatric practices.
Results
Several major themes were identified through in-depth qualita-
tive analysis and are now detailed and discussed. The key areas are
summarized as issues relating to lack of funding; training; treat-
ment; perceived difficulty and stigma; patient related; personal; and
other. All quoted material is excerpted from the students’ essays.
Lack of funding
Limited resources, leading to inability to provide
optimal care (n 29)
‘‘The sense of battling upstream without a paddle is very strong in
psychiatry. The burden of disease remains so high, funding is
woefully deficient and treatment advances seem slow and small’’ .
The most prevailing theme to emerge relates to a strong sense of
helplessness in the face of the chronic lack of resources in the public
health system. Commonly used adjectives were ‘‘discouraging’’,
‘‘demoralizing’’, ‘‘disheartening’’, ‘‘frustrating’’ and feeling
‘‘powerless’’. The dominant observation was that psychiatrists are
unable to perform a good job, or provide optimal treatment, as a
result of limited funding that impacts on the availability of
resources. As one student stated, there is a reluctance ‘‘to become
involved in an area where you have to ‘fight’ for adequate and
necessary resources’’ just to get the job done.
Shortage of beds (n13)
It was clear that most students were struck by the chronic bed
shortage during their terms and thus viewed psychiatry as an area
of medicine that is ‘‘overstretched’’. This was highlighted by one
student’s expressed frustration at being forced to make ‘‘admission
decisions with regard to the number of beds, not the needs of the
patient’’.
‘‘A shortage of resources also means a shortage of beds. Due to
this patients may need to be discharged slightly earlier than would
be ideal. To find a job rewarding, you should be able to perform
your duties to the best of your ability and to give the best possible
care to your patients. So there is a discrepancy between the ideal
way in which a psychiatrist could practise and the way in which
they are forced to practise’’.
Understaffed (n 22)
Staff shortages resulting in increased work burden and long
hours were also recorded as a significant feature negatively
impacting on the students’ clinical experience.
Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
727
Stress/pressure (n 14)
Naturally, the strain of working in a chronically underfunded
and inadequately staffed environment was perceived to generate
high pressure and stress.
Inadequate training (n 7)
Lack of funding was also implicated as having a detrimental
effect on the quality of teaching received during training rotations.
There was a strong sense of senior registrars being so busy that they
‘‘have little time or energy to invest in support or in nurturing a
suitable environment for trainees’’. One student also felt that
‘‘resident and intern psychiatry positions are more focused on
blood results and general medical care, rather than their actual
care’’. This indicates that some students felt that the environment
acted against optimal training, with trainees never adequately
taught practical skills in how best to deal with psychiatric patients.
This issue is of concern to psychiatry as a teaching profession
and raises an interesting issue as to whether more students would
choose to pursue a career in psychiatry if they received more
guidance, time and mentoring from their superiors during their
student allocation. This may be an area that requires more
consideration at a policy and pedagogical level.
Training issues
Exposure (n 6)
The concept of exposure was a significant theme, referring to two
different aspects of training. On the one hand, students commented
that exposure to the field of psychiatry comes ‘‘very late in
training’’ and that there was ‘‘no interest generated’’ throughout
their medical degree. Others referred to exposure in the sense that
what they see and experience during their practical training in the
wards presents a very ‘‘bleak and traumatic’’ view of working in the
field.
‘‘Exposure as medical students is purely to ‘acute’ psychiatry (i.e.
hospital-based crisis intervention), hence distorting the view of
general psychiatric practice’’.
Acute/crisis foci (n 7)
To experience psychiatric treatment only within an acute setting
was obviously overwhelming for many students. They commented
on the ‘‘frustrating cycle ’’ of relapse and continual presentation of
patients. To experience care only at the crisis end of the spectrum
gives a ‘‘distorted perspective’’ of working in psychiatry.
‘‘Psychiatrists are under a considerable amount of stress due to a
shortage of funding to mental health services. This shortage has
created a situation where most of the attention needs to be paid
towards the acute end of the spectrum. For a psychiatrist this
means that they mainly deal with patients who are acutely unwell
and often not very thankful for medical intervention. In addition, it
728 MEDICAL STUDENT VIEW OF PSYCHIATRY
is harder to achieve continuity of care due to long waiting lists.
Again this means that the job is not rewarding, because you don’t
get to see the positives as much’’.
In general, medical students’ exposure to the psychiatric field
results in an image of the profession as stressful, traumatic and
‘‘personally frustrating’’.
Treatment issues
Not ‘‘real medicine’’ (n20)
‘‘[Psychiatry is] very different to the rest of medicine. As we are
trained mainly to focus on medical illnesses, disease and physical
symptoms, some find it hard to understand psychiatry’’ .
A distinctive issue impacting on students’ views about not
entering a career in into psychiatry centred on the widespread
perception that psychiatry is ‘‘not real medicine’’. In general, it was
perceived as ‘‘unscientific’’, with ‘‘ambiguous’’ guidelines and
treatment strategies. Many students found that the uncertainties
surrounding diagnosis and treatment made it a ‘‘non-procedural
profession’’. For some, the fact that psychiatry is an area of
medicine that is ‘‘not always black and white’’ was a matter of
major concern. The typical perception is summed up by the
following statement:
‘‘Much of medicine is ‘evidence-based’ relying on clinical trials and
precise diagnoses. Psychiatry may be considered an imprecise art,
where basing practice on ‘evidence’ is more difficult than in other
specialties. Diagnoses are often not clear (until the wisdom of
retrospect can be applied) and we often treat based on symptoms,
rather than based on a fixed underlying diagnosis’’ .
Symptomatology versus aetiology (n19)
In general, students described psychiatry as a field of medicine
that is uncertain and at times even ‘‘very mysterious’’, and their
lack of confidence in the pathology of mental illness proved to be a
significant concern. The focus on symptoms, rather than aetiology
within psychiatric treatment, was regarded as inherently proble-
matic.
‘‘Many of the aetiological and neuropathological processes have
still not been elicited. While treatments are helpful they are far
from perfect. While offering massive potential for research
developments, it also means that people who like a solid under-
standing of the process of disease and treatment are not likely to be
attracted to the field of psychiatry’’ .
Increased risk of litigation (n 8)
Anxiety over treatment and diagnostic uncertainty appeared due
to beliefs that the exact causes of psychiatric illness and the precise
mechanisms of treatment are ‘‘poorly understood’’. This creates an
Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
underlying fear that an incorrect diagnosis could ‘‘potentially lead
to situations open to legal prosecution’’. Indeed, the risk of
litigation and the extensive legal requirements related to the Mental
Health Act and Mental Health Review Tribunal was an area of
concern for many.
‘‘Although the Mental Health Act and all it entails are designed to
protect the clinician and patient, often it seems that much of the
time spent in a day at the mental health unit is about notifying the
proper authorities rather than spending time with the patient’’ .
Limitations of DSM classification system (n5)
Further, many students believe the DSM classification system is
too restrictive, finding for example, that it lacks ‘‘intellectual
engagement with the psychology of mental illness’’. Others saw
its limitations in providing ‘‘arbitrary criteria’’. Clearly, the lack of
clear-cut pathology and treatment guidelines is a source of anxiety
that discourages some students from the field.
‘‘There is little certainty about diagnosis, and treatment is fairly
empirical . . . the lack of universal criteria often makes diagnosis
difficult, leading to problems in allowing for definitive treatment’’.
Reliance on pharmacology (n 11)
Some students objected to the excessive reliance on psychotropic
drugs in the treatment of psychiatric illness and to the fact that
there was ‘‘no time to utilize psychotherapy’’. The multi-disciplin-
ary nature of psychiatric care means that various therapies are
increasingly outsourced to other professions, particularly psychol-
ogists, leaving ‘‘no opportunity to engage on psychosocial ele-
ments’’.
‘‘Much of psychiatry is diagnosing and medication. The role of
psychotherapy and comprehensive management plan, including
support etc. is left for others to do, which makes the role of a
psychiatrist appear less interesting’’ .
Students thus felt that psychiatrists working in the public health
system are restricted to demonstrate expertise in only one element
of care, which is administering medication. For some, that means
the more interesting and challenging facets of psychiatric treatment
(i.e. psychological therapy) were being undertaken by other
professionals working in the mental health field.
No cures, no quick fix (n 13)
‘‘Many people prefer to be able to cure the patients as it serves to
give more job satisfaction’’.
In general, the view that there is ‘‘no cure’’ or quick fix for
mental illness generated feelings of dissatisfaction. Students stated
that it would be frustrating to put lots of effort and time into
patient contact in ongoing care ‘‘with no guaranteed results’’,
 T. WIGNEY, G. PARKER 729

making improvement ‘‘slow in comparison’’ to other domains of problematic, particularly for students who value more efficient
medicine. This culminates in a discouraging feeling that clinical results and less direct patient contact.
efforts and treatment strategies are ‘‘unsuccessful’’. For some, the
‘‘Rather than one discrete illness . . . psychiatrists have to be much
problem of patient compliance, as well as the reality that effective
more involved in the patient’s life and that can be daunting for
treatment is also highly dependent on the efforts of the patient, was
some. It is no longer about an illness treatment, but more about the
highlighted as an issue negatively impacting on the clinician’s
general issues in a person’s life’’ .
ability to provide optimal treatment outcomes and predict recov-
ery. At the core is an issue of power and control.
For such reasons, many students opted against a career in
‘‘While most non-mental health illnesses can be cured or at least
psychiatry, choosing a position more interesting even if not
ameliorated with minimal patient compliance, mental health is an
involving specialization. For example, some noted that they felt
area where the patient and their family often bear the burden of the
able to ‘‘practise psychiatry-related issues as a GP in less time’’ with
disease’’ .
no risk of ‘‘losing medical skills’’.

No treatment advances (n 5)
A related issue was the perception that there have been no
advances in treatment in comparison with other medical specialties,
which reflects the idea of psychiatry as an outdated and ‘‘un-
scientific’’ discipline. This belief is highlighted by the following
comments.
‘‘There is a lack of new medications in psychiatry that are
developed based on known mechanisms of action. In this regard,
psychiatry is not very advanced. Atypicals are slightly better than
the typcicals, but not by much!’’
In general, students expressed uneasiness about ‘‘conflicting
evidence about the efficacy of some psychiatric treatments’’. This
situation predictably reinforces decisions not to specialize as a
psychiatrist.
Perceived difficulty and stigma
Difficulty (n17)
‘‘It makes one feel guilty if I have to compel treatment against the
patient’s wish. Moreover, why should one treat if the patient is not
willing?’’
Another key theme that emerged can be summarized as the concept
of ‘‘difficulty’’. Psychiatry is perceived as an area of medicine that is
extremely challenging. Varying reasons were highlighted: (i)
patients do not always respond effectively; (ii) severe side-effects
of some medications; (iii) the chronic nature of psychiatric illnesses;
(iv) lack of compliance; (v) competing theories (i.e. confusion and
conflict between psychiatrists); (vi) highly demanding profession
(‘‘lots of effort is required to develop interviewing skills with non-
responsive patients’’); (vii) complicated issues (‘‘not just dealing
with discrete illness’’); (viii) a frustrating cycle of treatment (the
‘‘revolving door syndrome’’); (ix) dealing with patients who have
high rates of suicide; and (x) complications of patients with
personality disorders and comorbid substance abuse problems.
These factors, compounded with chronic shortage of staff, beds
and resources paint a dire picture of working in the mental health
system that does not encourage interest in specialization. The long-
term nature of the therapeutic relationships was also cited as
Stigma (n 20)
A significant number of students referred to ‘‘stigma’’ as a cause
for disinterest in psychiatry. This theme is highly concerning and
illustrates how entrenched stigmatizing attitudes towards the
mentally ill are, even within the medical profession. The implication
in this context was of ‘‘stigma by association’’. Students have
already experienced negative attitudes from practitioners in other
fields of medicine towards those working in psychiatry. It appears
that working with a stigmatized group such as the mentally ill made
the profession ‘‘less glamorous’’, something that clinicians may
want to distance themselves from and ‘‘not want to be associated
with’’. As one respondent stated, ‘‘to say you’re a psychiatrists is
like saying ‘witchdoctor’ ’’. There was also an underlying ‘‘fear that
exposure to mental illness will cause mental illness in self’’.
Patient-related issues
Aggressive patients/dangerous environment (n 13)
The issues of personal safety, fear of aggressive and violent
patients, and the ‘‘constant possibilities of harm, threats or
harassment’’ working in the wards was a consistent response. The
wards were seen as a dangerous environment in which the risks of
violence and assault are high. It was not clear whether this view of
psychiatry is based on difficulties personally experienced during
rotations, or whether the negative perception relates to discrimi-
nating evaluations as a result of stigma.
Patients harder to treat (n 9)
The belief that patients are more difficult to treat now, than in
the past, was also highlighted. It appears that the fact that
substance abuse is routinely involved in triggering psychotic
episodes creates a moral dilemma for some students about which
patients are worthy of treatment. This attitude is summed up by the
following comment.
‘‘The number of psychiatric admissions caused by substance abuse
has sky-rocketed in the past decade or so. Psychiatrists may be off-
put by the fact that these ‘self-inflicted’ psychiatric patients are
taking over the hospitals and resources, while the patients with

Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
730 MEDICAL STUDENT VIEW OF PSYCHIATRY
disorders such as schizophrenia and mania are being less well
attended to’’ .
While the cycle of treatment and relapse caused by vulnerability
to alcohol and illicit drug abuse is an understandable point of
frustration, it also indicates a lack of understanding as to why some
individuals engage in such destructive self-medicating behaviours
and the positive affect a psychiatrist can have on ameliorating such
problems. These views point to a significant gap in training.
Personal reasons
Lack of personal skills (n 19)
Understandably, students also had personal reasons for not
wishing to pursue a career in psychiatry. Some find the high level of
patient contact required a turn-off. For example, some ‘‘preferred
pathology to having to talk to patients’’ and disliked the level of
interaction skills that are also necessary in an area of medicine that
‘‘requires teamwork and communication’’.
Others stated that attributes of sensitivity and empathy may not
come naturally and were ‘‘difficult to master’’.
‘‘Doctors are overrepresented with narcissistic traits and perfec-
tionistic traits. Some with obsessive
compulsive traits as well.
These are people very pre-occupied with their own thoughts, sense
of entitlement and lack of empathy. Despite training to empathize
with the patient, training in psychiatry requires real empathy,
which many doctors lack’’ .
There was also a widespread view that working with mentally ill
patients is simply too hard
either personally ‘‘demanding’’ or
‘‘emotionally draining’’. There was an underlying fear that being in
close proximity to mental illness would have negative personal
consequences, with the belief, for example, that ‘‘spending time
with patients who are depressed seems to suck the happiness out of
you’’ or the ‘‘fear that one will go mad if that’s all they do’’.
Some acknowledged that the inability to help patients improve
may be interpreted as a personal sign of failure. Others were simply
uncomfortable working in an area of medicine where they felt they
had ‘‘no power or control’’. The need to retain power and control
was central to many responses, but is most alarmingly summed up
by one student.
‘‘In the past, mental asylums were run with more physical and
pharmacological restraints in place. This is not acceptable from a
treatment or human rights point of view. However, it did give the
physician a higher sense of power and control over his patients’’ .
This comment, while very confronting, is significant in drawing
attention to the undercurrent of fear and stigma that exists for
some students when contemplating working with psychiatric
patients, and a countering need for control.
Low job satisfaction (n24)
The lack of job satisfaction, low appreciation and limited
fulfilment was a consistent theme. In general, psychiatry was
Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
viewed as a field of medicine in which there is minimal gratitude,
lack of respect and a lowered sense of personal reward. Students
felt that you ‘‘do not get to feel the satisfaction of a ‘job well
done’ ’’. Being unable to deliver optimal treatment due to poor
access to rehabilitation services and lack of funding, results in poor
outcomes that are viewed as ‘‘professionally dissatisfying’’. This
view is highlighted by one student who comments that, in
psychiatry:
‘‘. . . disease processes are chronic and confronting. Dealing with
people whose illness is causing debilitating social, occupational and
forensic effects is challenging to one’s self as a clinician. The
perception that treatments often fail and little improvement is
gained can make the thought of a life in psychiatric practice
deficient in rewards’’ .
The fact that many patients ‘‘don’t want help’’ was also a point
of contention, as it negatively impacts on the clinician’s sense of
being appreciated and respected. Indeed, some students simply
objected to working in a field of medicine in which patients have to
be detained against their will. The fact that clinicians do not receive
much gratitude from patients was also interpreted as a discouraging
factor.
Low prestige/respect (n 24)
There was a very strong sense that psychiatry is a specialty in
which there is low prestige and little community and professional
respect. In general, psychiatrists are perceived to be ‘‘looked down
upon’’, particularly among peers. The fact that the ‘‘community
fails to distinguish between psychiatrist and psychologist’’ was also
highlighted as problematic.
Income (n 21)
Many students reasoned that the comparatively low remunera-
tion psychiatrists received was a valid reason for reduced rates of
recruitment. The issue of salary (reward system) could be linked to
expectations relating to professional prestige.
Other
Paperwork/No lifestyle balance (n 10)
Finally, the fact that there is a requirement to complete lots of
paperwork (particularly in relation to legal matters) and to work
hours ‘on-call’ meant that psychiatry is regarded as a medical
specialty that does not afford a healthy lifestyle balance. The
increased amount of ‘‘red tape’’ was also felt by some to impinge on
their ability to give quality care to their patients.
Unsupportive working environment (n 8)
Some students commented that psychiatrists do not receive much
support from colleagues or other specialists, thus contributing to a
sense of psychiatrists being very much on their own within the
 T. WIGNEY, G. PARKER
hospital system. Some indicated that ‘‘inappropriate referral’’,
particularly by sections of hospitals that attempt to ‘‘palm off’’
patients to psychiatry, was a source of frustration.
General
Other reasons cited for the reduction in recruitment were
stereotyping of psychiatrists (although this comment was not
explained further); requirements to work in rural areas; high rates
of suicide among the profession; and low family support for the
decision to become a psychiatrist.
Discussion
In general, the medical students’ attitude towards a
career in psychiatry can be summarized in the words
of one student:
Although the study of psychiatry has its rewards in
better understanding of people and everyday interac-
tions, the practice of psychiatry is an entirely
different story, where there often seem to be more
negatives than positives.
Issues relating to the limitations of treatment, lack
of funding and the ‘‘unscientific’’ nature of psychiatry
emerged as key themes. The relationship between low
prestige, lack of (professional) respect and stigma is
also apparent and points to a worrying trend that
psychiatrists are negatively perceived within the
broader hierarchy of the medical profession due to
their association with mental illness and the ‘‘ambig-
uous’’ nature of treatment. Again, this highlights an
alarming attitude and it is matter of concern that such
a stigmatizing perspective is allowed to take root
during the formative years of medical training.
The very negative evaluation of psychiatry as a
career overviewed here needs to be balanced against
the reality that the question was designed to elicit
negative perceptions gained by students during their
exposure to clinical psychiatry, and did not seek
positive views. In many ways this question can be
Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
731
viewed as akin to a stage in any SWOT (Strengths,
Weaknesses, Opportunities and Threats) analysis,
where the overall aim is to identify strengths, weak-
nesses, opportunities and threats, and that the current
focus was only on the weaknesses. Our medical
students who read this article can therefore predict
next term’s question.
In a previous study we surveyed the attitudes of
medical students early in their medical courses at six
differing Australian universities, and prior to their
exposure to clinical psychiatry [1]. Their image of
psychiatry was distinctly more positive, with students
prejudging psychiatry as interesting and intellectually
challenging, and providing a career that promised job
satisfaction with good prospects and enjoyable work.
After discounting the bias of the question faced by
students in the current study, it would appear likely
that actual exposure of medical students to clinical
psychiatry is a key factor in generating a set of
negative judgments. If true, there are several major
implications. In addition to those impacting on how
to structure clinical psychiatry training, there is the
wider issue
that the students’ judgements are in line
with many other commentators (including psychia-
trists, other mental health practitioners and consu-
mers). These broader problems in the practise of
psychiatry, particularly in the public sector, need to
be addressed.
If psychiatry is to attract high-quality trainees and
future psychiatrists, there is clearly a need to provide
positive educational experiences for medical students
that excite their imagination about a career or even a
calling, rather than merely viewing it as an unsatis-
factory job. Currently, medical students, like canaries
in the mine, are sending a perturbing signal.
Reference
1. Malhi GS, Parker GB, Parker K et al . Shrinking away from
psychiatry? A survey of Australian medical students’ interest in
psychiatry. Aust N Z J Psychiatry 2002; 36:416
423.