Psychiatrists often blame medical students’ lack of interest in their specialty on perceptions that psychiatrists earn less and endure lower status than other physicians. It turns out, however, that if psychiatric educators want to recruit more medical students to their field, the factor they need to deal with first is students’ perception that treating psychiatric patients is so stressful it makes the prospect of becoming a psychiatrist intolerable.

Psychiatrist Janis Cutler, M.D., examined the factors influencing this surprising response by conducting semistructured interviews with 59 medical students. They were interviewed over a three-year period just prior to graduation and were paid between $20 and $25 for their participation. Interviews took about one hour each.

She decided to interview medical students after a study she conducted in the mid-1990s revealed the strong impact that perceived high levels of stress had on the students’ decision to choose a field other than psychiatry.

Cutler, who is codirector of medical student education in psychiatry and an associate clinical professor at Columbia University College of Physicians and Surgeons, hypothesized that a substantial portion of students’ notion that psychiatry was more stressful than other specialties came from observing or receiving messages—overt or subtle—from psychiatry attendings and residents. The students indicated, however, that they did not perceive these psychiatry teachers as any more stressed out than the other physicians they encountered during medical school.

Their views of psychiatry developed more from their assessments of what constituted a good fit for their personalities and what a lifetime career entailed, which they derived from both personal experiences with psychiatric treatment and their psychiatry clerkships, explained Cutler.

Speaking at the June annual meeting of the Association of Directors of Medical Student Education in Psychiatry in Santa Fe, N.M., Cutler pointed out that more than one-third of the students said their clinical work with psychiatric patients was more stressful than it was in other rotations and that this influenced them to choose another medical field. They used phrases to describe psychiatric treatment such as "emotionally draining," "too overwhelming," "requires too much personal investment," "chronic patients are too frustrating to deal with," "the patients make me uncomfortable and are frightening," and "I don’t want to get so deep into other people’s lives." For students who had received psychiatric treatment or who had a relative or significant other who had done so, their views of psychiatry were influenced by how they interpreted their or their loved ones’ experience.

While none of the students who had perceived a bad experience chose to enter psychiatry, several of the students with a positive view of psychiatric care rejected a psychiatry career because they could not envision dealing daily "with people like themselves," Cutler said. If family members had a positive experience with psychiatry, the student was more willing to give serious consideration to the specialty, she added.

Many of the medical students said they were turned off to psychiatry, Cutler noted, because they could not put up with the delayed gratification that comes with curing patients over a long course of treatment—they looked forward to a career in which they would see immediate or at least rapid results from their care. Some of the students also pointed out their frustration with psychiatry’s prohibition against touching patients.

Almost all of the students, however, did indicate that the clerkship and classroom exposure they had to psychiatry would have an impact on the way they would treat their patients in the future, Cutler said.

The surveyed students’ decision against pursuing a psychiatric career did not mean that they had an overall negative view of the specialty. In fact, she noted, they had a "reasonably accurate idea" of what psychiatry entails and did not reveal many "major distortions." The majority said they found "the intellectual aspects interesting," she pointed out, and most said that they came away from their psychiatry clerkships with a more positive perception of the field, particularly its ability to treat patients successfully with medications.

Cutler suggested that the timing of her interviews just a few weeks before the students graduated might have influenced their responses. "They all seemed so sure" of their career choice, she said, which may indicate "some degree of rationalization that they made the right decision." It might have been too anxiety provoking to analyze their decision at this point in their education, she said.

She wondered whether it would be easier to recruit medical students to psychiatry if their clerkships involved them in more outpatient treatment where the patients would not be as severely ill and stress inducing as the hospitalized ones to whom they are often exposed.

It might also help if their psychiatrist teachers dealt with the stress issue in the first days of psychiatry clerkships. Students’ aversion to taking on what they perceive as stressful interactions could be mitigated if clerkship directors guided them to finding "a balance between being empathic and not becoming merged or overidentified with patients," Cutler said. She noted that she tells students on the first day of their psychiatry rotation that as their training progresses, they will get better at striking that balance and will learn to go home at the end of the day and not ruminate on their patients’ problems.