May 7, 1999

The results of a new survey may explain in part why only about 3 percent of medical students choose to specialize in psychiatry. Incoming first-year medical students have a fairly negative image of psychiatry that worsens during their training.

"Our interactions with nonpsychiatric colleagues, patients, and even friends and family are often colored at times by a fairly pronounced stigma toward psychiatry," said Christine Moutier, M.D., at the March meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in Santa Monica, Calif. Moutier is chief resident in the department of psychiatry at the University of California at San Diego (UCSD) Medical Center.

She and her colleague surveyed about 750 students at the medical schools of UCSD, University of California at Irvine, and University of Texas at Houston from 1994 to 1995, and 450 responded. The medical students were surveyed at the beginning of their first year, middle of their second year, and end of their fourth year, noted Moutier.

Psychiatry was the first career choice for only .4 percent of first-year students surveyed, compared with 13 percent who indicated that psychiatry was their top choice in a 1970 study.

Psychiatry was a strong career choice for about 7 percent of first-year medical students in 1994 compared with 11 percent of first-year medical students in a 1980 study, according to Moutier.

In addition, 62 percent of medical students in 1994 said it was unlikely they would choose psychiatry compared with 28 percent in 1980.

Psychiatry as a career choice ranked much lower than primary care (family medicine and internal medicine), surgery, obstetrics/gynecology, and pediatrics. Medical students also rated psychiatry much lower in terms of treatment efficacy, scientific foundation, bright and interesting future, and being a rapidly advancing field in medicine.

"These low scores were surprising given the scientific advances in the field, especially in the last decade," said Moutier. "It shows the need for further education of our colleagues and society in general."

Respondents respected psychiatrists' skills and knowledge much less than those of the other five physician specialties, said Moutier. Perhaps more disturbing was that respondents believed that their family, classmates, and attending physicians respected psychiatrists' skills even less. For example, 56 percent of incoming freshmen viewed psychiatrists' skills and knowledge positively, compared with their impression that 32 percent of other physicians, 40 percent of their classmates, and 40 percent for their family held that same view, according to the study.

The converse was also true: 10 percent of freshmen had a negative view of psychiatrists' skills compared with their belief that 24 percent for physicians did, 14 percent for classmates, and 26 percent for family.

By the second year, medical students had a less positive view of psychiatry especially regarding job satisfaction, helping patients, use of training, prestige, and association with colleagues. The only attribute that was perceived more positively was psychiatrists' lifestyle because of the perception of a less demanding schedule, noted Moutier.

Medical students' interest level in psychiatry as a career also declined sharply from about 8 percent in their first year to 3 percent in the second year. Their attitude toward psychiatry also decreased significantly during that period, from 8 percent to -6 percent.

"The socialization process in the first two years of medical school only tends to increase students' negative views of psychiatry. This needs to be counterbalanced with first-year courses in psychiatry taught by psychiatrists who reach out to students," said Moutier.

Fourth-year medical students rated the field of psychiatry even lower than had second-year students on such attributes as interesting, intellectually stimulating, rapidly advancing, and scientific foundation, according to the study.

The factors that had a positive influence on students' views of psychiatry in their second and fourth years were college courses, preclinical courses such as psychopathology, and contact with patients and faculty. However, with the exception of college courses, these factors had a less positive impact by the fourth year.

The negative factors in their second and fourth years were media portrayal and the attitudes of their families, physicians, and colleagues, noted the study.

With the exception of media portrayal, these factors played a dramatically more negative role in influencing students' attitudes toward psychiatry by their fourth year, especially colleagues' attitudes.

Moutier commented, "When I chose psychiatry in my third year of medical school, I was surprised by the strong negative reactions of residents and attending physicians. A typical response was, 'Psychiatry is a waste of your talents and medical education.' "-C.L.