You are on page 1of 6

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 informed observers of the psychiatric system  albeit
doctors apply for training in psychiatry, while those with a distinct focus on the public psychiatric sector.
who take up training are more likely to report
demoralization and to cease such training. While
many psychiatrists would be readily able to offer Method
multiple reasons for dissatisfaction with a career in
psychiatry, it appeared useful to obtain the view of 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
Gordon Parker, Scientia Professor, School of Psychiatry, University of might be less likely to train in psychiatry these days than
New South Wales and Executive Director, Black Dog Institute
(Correspondence); and Tessa Wigney, PhD student, School of
previously’’, along with nine other questions in a 2 h examination.
Psychiatry, University of New South Wales. Answers were collated and qualitatively and quantitatively ana-
Black Dog Institute, Prince of Wales Hospital, Randwick, NSW 2031, lysed.
Australia. Email: g.parker@unsw.edu.au All students had completed a 10 week term in psychiatry, and
Received 12 June 2007; accepted 13 June 2007. 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 727

hospital units, with most having some exposure to community Stress/pressure (n 14)
psychiatric teams and some having limited exposure to private
psychiatric practices.
Naturally, the strain of working in a chronically underfunded
and inadequately staffed environment was perceived to generate
high pressure and stress.
Results
Inadequate training (n 7)
Several major themes were identified through in-depth qualita-
tive analysis and are now detailed and discussed. The key areas are Lack of funding was also implicated as having a detrimental
summarized as issues relating to lack of funding; training; treat- effect on the quality of teaching received during training rotations.
ment; perceived difficulty and stigma; patient related; personal; and There was a strong sense of senior registrars being so busy that they
other. All quoted material is excerpted from the students’ essays. ‘‘have little time or energy to invest in support or in nurturing a
suitable environment for trainees’’. One student also felt that
Lack of funding ‘‘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
Limited resources, leading to inability to provide
acted against optimal training, with trainees never adequately
optimal care (n 29) taught practical skills in how best to deal with psychiatric patients.
This issue is of concern to psychiatry as a teaching profession
‘‘The sense of battling upstream without a paddle is very strong in and raises an interesting issue as to whether more students would
psychiatry. The burden of disease remains so high, funding is choose to pursue a career in psychiatry if they received more
woefully deficient and treatment advances seem slow and small’’ . guidance, time and mentoring from their superiors during their
student allocation. This may be an area that requires more
The most prevailing theme to emerge relates to a strong sense of consideration at a policy and pedagogical level.
helplessness in the face of the chronic lack of resources in the public
health system. Commonly used adjectives were ‘‘discouraging’’,
Training issues
‘‘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 Exposure (n 6)
result of limited funding that impacts on the availability of
resources. As one student stated, there is a reluctance ‘‘to become The concept of exposure was a significant theme, referring to two
involved in an area where you have to ‘fight’ for adequate and different aspects of training. On the one hand, students commented
necessary resources’’ just to get the job done. that exposure to the field of psychiatry comes ‘‘very late in
training’’ and that there was ‘‘no interest generated’’ throughout
Shortage of beds (n13) 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
It was clear that most students were struck by the chronic bed
field.
shortage during their terms and thus viewed psychiatry as an area
of medicine that is ‘‘overstretched’’. This was highlighted by one ‘‘Exposure as medical students is purely to ‘acute’ psychiatry (i.e.
student’s expressed frustration at being forced to make ‘‘admission hospital-based crisis intervention), hence distorting the view of
decisions with regard to the number of beds, not the needs of the general psychiatric practice’’.
patient’’.

‘‘A shortage of resources also means a shortage of beds. Due to


this patients may need to be discharged slightly earlier than would Acute/crisis foci (n 7)
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 To experience psychiatric treatment only within an acute setting
care to your patients. So there is a discrepancy between the ideal was obviously overwhelming for many students. They commented
way in which a psychiatrist could practise and the way in which on the ‘‘frustrating cycle ’’ of relapse and continual presentation of
they are forced to practise’’. 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


Understaffed (n 22) shortage of funding to mental health services. This shortage has
created a situation where most of the attention needs to be paid
Staff shortages resulting in increased work burden and long towards the acute end of the spectrum. For a psychiatrist this
hours were also recorded as a significant feature negatively means that they mainly deal with patients who are acutely unwell
impacting on the students’ clinical experience. and often not very thankful for medical intervention. In addition, it

Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
728 MEDICAL STUDENT VIEW OF PSYCHIATRY

is harder to achieve continuity of care due to long waiting lists. underlying fear that an incorrect diagnosis could ‘‘potentially lead
Again this means that the job is not rewarding, because you don’t to situations open to legal prosecution’’. Indeed, the risk of
get to see the positives as much’’. litigation and the extensive legal requirements related to the Mental
Health Act and Mental Health Review Tribunal was an area of
In general, medical students’ exposure to the psychiatric field concern for many.
results in an image of the profession as stressful, traumatic and
‘‘Although the Mental Health Act and all it entails are designed to
‘‘personally frustrating’’.
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
Treatment issues proper authorities rather than spending time with the patient’’ .

Not ‘‘real medicine’’ (n20)


Limitations of DSM classification system (n5)
‘‘[Psychiatry is] very different to the rest of medicine. As we are
trained mainly to focus on medical illnesses, disease and physical
Further, many students believe the DSM classification system is
symptoms, some find it hard to understand psychiatry’’ .
too restrictive, finding for example, that it lacks ‘‘intellectual
engagement with the psychology of mental illness’’. Others saw
A distinctive issue impacting on students’ views about not its limitations in providing ‘‘arbitrary criteria’’. Clearly, the lack of
entering a career in into psychiatry centred on the widespread clear-cut pathology and treatment guidelines is a source of anxiety
perception that psychiatry is ‘‘not real medicine’’. In general, it was that discourages some students from the field.
perceived as ‘‘unscientific’’, with ‘‘ambiguous’’ guidelines and
treatment strategies. Many students found that the uncertainties ‘‘There is little certainty about diagnosis, and treatment is fairly
surrounding diagnosis and treatment made it a ‘‘non-procedural empirical . . . the lack of universal criteria often makes diagnosis
profession’’. For some, the fact that psychiatry is an area of difficult, leading to problems in allowing for definitive treatment’’.
medicine that is ‘‘not always black and white’’ was a matter of
major concern. The typical perception is summed up by the
following statement: Reliance on pharmacology (n 11)
‘‘Much of medicine is ‘evidence-based’ relying on clinical trials and
precise diagnoses. Psychiatry may be considered an imprecise art, Some students objected to the excessive reliance on psychotropic
where basing practice on ‘evidence’ is more difficult than in other drugs in the treatment of psychiatric illness and to the fact that
specialties. Diagnoses are often not clear (until the wisdom of there was ‘‘no time to utilize psychotherapy’’. The multi-disciplin-
retrospect can be applied) and we often treat based on symptoms, ary nature of psychiatric care means that various therapies are
rather than based on a fixed underlying diagnosis’’ . increasingly outsourced to other professions, particularly psychol-
ogists, leaving ‘‘no opportunity to engage on psychosocial ele-
ments’’.
Symptomatology versus aetiology (n19) ‘‘Much of psychiatry is diagnosing and medication. The role of
psychotherapy and comprehensive management plan, including
In general, students described psychiatry as a field of medicine support etc. is left for others to do, which makes the role of a
that is uncertain and at times even ‘‘very mysterious’’, and their psychiatrist appear less interesting’’ .
lack of confidence in the pathology of mental illness proved to be a
significant concern. The focus on symptoms, rather than aetiology
Students thus felt that psychiatrists working in the public health
within psychiatric treatment, was regarded as inherently proble-
system are restricted to demonstrate expertise in only one element
matic.
of care, which is administering medication. For some, that means
‘‘Many of the aetiological and neuropathological processes have the more interesting and challenging facets of psychiatric treatment
still not been elicited. While treatments are helpful they are far (i.e. psychological therapy) were being undertaken by other
from perfect. While offering massive potential for research professionals working in the mental health field.
developments, it also means that people who like a solid under-
standing of the process of disease and treatment are not likely to be No cures, no quick fix (n 13)
attracted to the field of psychiatry’’ .
‘‘Many people prefer to be able to cure the patients as it serves to
give more job satisfaction’’.
Increased risk of litigation (n 8)
In general, the view that there is ‘‘no cure’’ or quick fix for
Anxiety over treatment and diagnostic uncertainty appeared due mental illness generated feelings of dissatisfaction. Students stated
to beliefs that the exact causes of psychiatric illness and the precise that it would be frustrating to put lots of effort and time into
mechanisms of treatment are ‘‘poorly understood’’. This creates an patient contact in ongoing care ‘‘with no guaranteed results’’,

Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
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’’.

Stigma (n 20)
No treatment advances (n 5)
A significant number of students referred to ‘‘stigma’’ as a cause
A related issue was the perception that there have been no
for disinterest in psychiatry. This theme is highly concerning and
advances in treatment in comparison with other medical specialties,
illustrates how entrenched stigmatizing attitudes towards the
which reflects the idea of psychiatry as an outdated and ‘‘un-
mentally ill are, even within the medical profession. The implication
scientific’’ discipline. This belief is highlighted by the following
in this context was of ‘‘stigma by association’’. Students have
comments.
already experienced negative attitudes from practitioners in other
‘‘There is a lack of new medications in psychiatry that are fields of medicine towards those working in psychiatry. It appears
developed based on known mechanisms of action. In this regard, that working with a stigmatized group such as the mentally ill made
psychiatry is not very advanced. Atypicals are slightly better than the profession ‘‘less glamorous’’, something that clinicians may
the typcicals, but not by much!’’ want to distance themselves from and ‘‘not want to be associated
with’’. As one respondent stated, ‘‘to say you’re a psychiatrists is
In general, students expressed uneasiness about ‘‘conflicting like saying ‘witchdoctor’ ’’. There was also an underlying ‘‘fear that
evidence about the efficacy of some psychiatric treatments’’. This exposure to mental illness will cause mental illness in self’’.
situation predictably reinforces decisions not to specialize as a
psychiatrist.
Patient-related issues
Perceived difficulty and stigma
Aggressive patients/dangerous environment (n 13)
Difficulty (n17)
The issues of personal safety, fear of aggressive and violent
patients, and the ‘‘constant possibilities of harm, threats or
‘‘It makes one feel guilty if I have to compel treatment against the
harassment’’ working in the wards was a consistent response. The
patient’s wish. Moreover, why should one treat if the patient is not
wards were seen as a dangerous environment in which the risks of
willing?’’
violence and assault are high. It was not clear whether this view of
Another key theme that emerged can be summarized as the concept psychiatry is based on difficulties personally experienced during
of ‘‘difficulty’’. Psychiatry is perceived as an area of medicine that is rotations, or whether the negative perception relates to discrimi-
extremely challenging. Varying reasons were highlighted: (i) nating evaluations as a result of stigma.
patients do not always respond effectively; (ii) severe side-effects
of some medications; (iii) the chronic nature of psychiatric illnesses; Patients harder to treat (n 9)
(iv) lack of compliance; (v) competing theories (i.e. confusion and
conflict between psychiatrists); (vi) highly demanding profession
The belief that patients are more difficult to treat now, than in
(‘‘lots of effort is required to develop interviewing skills with non-
the past, was also highlighted. It appears that the fact that
responsive patients’’); (vii) complicated issues (‘‘not just dealing
substance abuse is routinely involved in triggering psychotic
with discrete illness’’); (viii) a frustrating cycle of treatment (the
episodes creates a moral dilemma for some students about which
‘‘revolving door syndrome’’); (ix) dealing with patients who have
patients are worthy of treatment. This attitude is summed up by the
high rates of suicide; and (x) complications of patients with
following comment.
personality disorders and comorbid substance abuse problems.
These factors, compounded with chronic shortage of staff, beds ‘‘The number of psychiatric admissions caused by substance abuse
and resources paint a dire picture of working in the mental health has sky-rocketed in the past decade or so. Psychiatrists may be off-
system that does not encourage interest in specialization. The long- put by the fact that these ‘self-inflicted’ psychiatric patients are
term nature of the therapeutic relationships was also cited as 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 viewed as a field of medicine in which there is minimal gratitude,
attended to’’ . lack of respect and a lowered sense of personal reward. Students
While the cycle of treatment and relapse caused by vulnerability felt that you ‘‘do not get to feel the satisfaction of a ‘job well
to alcohol and illicit drug abuse is an understandable point of done’ ’’. Being unable to deliver optimal treatment due to poor
access to rehabilitation services and lack of funding, results in poor
frustration, it also indicates a lack of understanding as to why some
individuals engage in such destructive self-medicating behaviours outcomes that are viewed as ‘‘professionally dissatisfying’’. This
and the positive affect a psychiatrist can have on ameliorating such view is highlighted by one student who comments that, in
psychiatry:
problems. These views point to a significant gap in training.
‘‘. . . disease processes are chronic and confronting. Dealing with
people whose illness is causing debilitating social, occupational and
Personal reasons
forensic effects is challenging to one’s self as a clinician. The
perception that treatments often fail and little improvement is
Lack of personal skills (n 19) gained can make the thought of a life in psychiatric practice
deficient in rewards’’ .
Understandably, students also had personal reasons for not
wishing to pursue a career in psychiatry. Some find the high level of The fact that many patients ‘‘don’t want help’’ was also a point
patient contact required a turn-off. For example, some ‘‘preferred of contention, as it negatively impacts on the clinician’s sense of
pathology to having to talk to patients’’ and disliked the level of being appreciated and respected. Indeed, some students simply
interaction skills that are also necessary in an area of medicine that objected to working in a field of medicine in which patients have to
‘‘requires teamwork and communication’’. be detained against their will. The fact that clinicians do not receive
Others stated that attributes of sensitivity and empathy may not much gratitude from patients was also interpreted as a discouraging
come naturally and were ‘‘difficult to master’’. factor.
‘‘Doctors are overrepresented with narcissistic traits and perfec-
tionistic traits. Some with obsessive  compulsive traits as well. Low prestige/respect (n 24)
These are people very pre-occupied with their own thoughts, sense
of entitlement and lack of empathy. Despite training to empathize There was a very strong sense that psychiatry is a specialty in
with the patient, training in psychiatry requires real empathy, which there is low prestige and little community and professional
which many doctors lack’’ . respect. In general, psychiatrists are perceived to be ‘‘looked down
upon’’, particularly among peers. The fact that the ‘‘community
There was also a widespread view that working with mentally ill fails to distinguish between psychiatrist and psychologist’’ was also
patients is simply too hard  either personally ‘‘demanding’’ or highlighted as problematic.
‘‘emotionally draining’’. There was an underlying fear that being in
close proximity to mental illness would have negative personal Income (n 21)
consequences, with the belief, for example, that ‘‘spending time
with patients who are depressed seems to suck the happiness out of
Many students reasoned that the comparatively low remunera-
you’’ or the ‘‘fear that one will go mad if that’s all they do’’.
tion psychiatrists received was a valid reason for reduced rates of
Some acknowledged that the inability to help patients improve
recruitment. The issue of salary (reward system) could be linked to
may be interpreted as a personal sign of failure. Others were simply
expectations relating to professional prestige.
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 Other
by one student.

‘‘In the past, mental asylums were run with more physical and Paperwork/No lifestyle balance (n 10)
pharmacological restraints in place. This is not acceptable from a
treatment or human rights point of view. However, it did give the Finally, the fact that there is a requirement to complete lots of
physician a higher sense of power and control over his patients’’ . paperwork (particularly in relation to legal matters) and to work
hours ‘on-call’ meant that psychiatry is regarded as a medical
This comment, while very confronting, is significant in drawing specialty that does not afford a healthy lifestyle balance. The
attention to the undercurrent of fear and stigma that exists for increased amount of ‘‘red tape’’ was also felt by some to impinge on
some students when contemplating working with psychiatric their ability to give quality care to their patients.
patients, and a countering need for control.
Unsupportive working environment (n 8)
Low job satisfaction (n24)
Some students commented that psychiatrists do not receive much
The lack of job satisfaction, low appreciation and limited support from colleagues or other specialists, thus contributing to a
fulfilment was a consistent theme. In general, psychiatry was sense of psychiatrists being very much on their own within the

Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015
T. WIGNEY, G. PARKER 731

hospital system. Some indicated that ‘‘inappropriate referral’’, viewed as akin to a stage in any SWOT (Strengths,
particularly by sections of hospitals that attempt to ‘‘palm off’’ Weaknesses, Opportunities and Threats) analysis,
patients to psychiatry, was a source of frustration.
where the overall aim is to identify strengths, weak-
nesses, opportunities and threats, and that the current
General focus was only on the weaknesses. Our medical
students who read this article can therefore predict
Other reasons cited for the reduction in recruitment were
next term’s question.
stereotyping of psychiatrists (although this comment was not
In a previous study we surveyed the attitudes of
explained further); requirements to work in rural areas; high rates
of suicide among the profession; and low family support for the
medical students early in their medical courses at six
decision to become a psychiatrist. differing Australian universities, and prior to their
exposure to clinical psychiatry [1]. Their image of
psychiatry was distinctly more positive, with students
Discussion prejudging psychiatry as interesting and intellectually
challenging, and providing a career that promised job
In general, the medical students’ attitude towards a satisfaction with good prospects and enjoyable work.
career in psychiatry can be summarized in the words After discounting the bias of the question faced by
of one student: students in the current study, it would appear likely
that actual exposure of medical students to clinical
Although the study of psychiatry has its rewards in psychiatry is a key factor in generating a set of
better understanding of people and everyday interac- negative judgments. If true, there are several major
tions, the practice of psychiatry is an entirely implications. In addition to those impacting on how
different story, where there often seem to be more to structure clinical psychiatry training, there is the
negatives than positives. wider issue  that the students’ judgements are in line
with many other commentators (including psychia-
Issues relating to the limitations of treatment, lack trists, other mental health practitioners and consu-
of funding and the ‘‘unscientific’’ nature of psychiatry mers). These broader problems in the practise of
emerged as key themes. The relationship between low psychiatry, particularly in the public sector, need to
prestige, lack of (professional) respect and stigma is be addressed.
also apparent and points to a worrying trend that If psychiatry is to attract high-quality trainees and
psychiatrists are negatively perceived within the future psychiatrists, there is clearly a need to provide
broader hierarchy of the medical profession due to positive educational experiences for medical students
their association with mental illness and the ‘‘ambig- that excite their imagination about a career or even a
uous’’ nature of treatment. Again, this highlights an calling, rather than merely viewing it as an unsatis-
alarming attitude and it is matter of concern that such factory job. Currently, medical students, like canaries
a stigmatizing perspective is allowed to take root in the mine, are sending a perturbing signal.
during the formative years of medical training.
The very negative evaluation of psychiatry as a
career overviewed here needs to be balanced against
Reference
the reality that the question was designed to elicit
negative perceptions gained by students during their
1. Malhi GS, Parker GB, Parker K et al . Shrinking away from
exposure to clinical psychiatry, and did not seek psychiatry? A survey of Australian medical students’ interest in
positive views. In many ways this question can be psychiatry. Aust N Z J Psychiatry 2002; 36:416  423.

Downloaded from anp.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 5, 2015