Psychiatry as a career choice compared with other specialties: a survey of medical students

AIMS AND METHOD The aim of this study was to determine the attitudes of medical students in 
the UK towards different specialties as career options and to ascertain the 
position of psychiatry among these specialties. Students belonging to a London 
medical school completed a questionnaire. RESULTS Among the 301 students who completed the survey, psychiatry was the least 
popular clinical specialty. The study revealed that the students had a number 
of misconceptions about psychiatry. A family history of mental illness was 
significantly associated with choosing psychiatry as a career. CLINICAL IMPLICATIONS Considering the unpopularity of the specialty, it is likely that 
recruitment of psychiatrists will continue to be a major problem for the 
foreseeable future. Measures need to be taken to dispel the misconceptions 
about psychiatry.

The aim of this study was to determine the attitudes of medical students in the UK towards different specialties as career options and to ascertain the position of psychiatry among these specialties. Students belonging to a London medical school completed a questionnaire.

RESULTS
Among the 301 students who completed the survey, psychiatry was the least popular clinical specialty. The study revealed that the students had a number of misconceptions about psychiatry. A family history of mental illness was significantly associated with choosing psychiatry as a career.

CLINICAL IMPLICATIONS
Considering the unpopularity of the specialty, it is likely that recruitment of psychiatrists will continue to be a major problem for the foreseeable future. Measures need to be taken to dispel the misconceptions about psychiatry.
Previous studies investigating the attitudes of medical students towards psychiatry have consistently shown that they hold a number of negative views about the specialty. For example, Furnham (1986) and Yellowlees et al (1990) reported that medical students perceived psychiatry as the specialty of lowest status. Medical students have also been shown to have negative preconceptions about psychiatrists: in a study by Eagle & Marcos (1980), psychiatrists were considered by the students to be emotionally unstable, confused and lower in competence than surgeons and physicians.
The proportion of medical students wanting to become psychiatrists is also significantly lower than that needed to serve the population (Storer, 2002). However, it has been shown that changing specialties is quite common; Parkhouse & Ellin (1988) found that two-thirds of doctors changed their initial career choice at least once within 7 years of qualifying. The role of the clinical posting or clerkship in psychiatry in changing attitudes of medical students towards the specialty has also been looked into. Although some studies (Burra et al, 1982;Shelley & Webb, 1986) have suggested that the clinical posting makes the attitude more positive, other studies (Galletly et al, 1995) have found little or no change as a result. A related study (Maidment et al, 2003) involving sixth-form students showed a surprising level of interest in psychiatry, with 12.4% wanting to pursue careers as psychiatrists. Nevertheless, recruitment and retention of psychiatrists continues to be a major problem in the UK, where 12% of consultant psychiatrist posts remain vacant (Royal College of Psychiatrists, 2002). In this context, identifying any misconceptions among medical students and changing the curriculum to address these could play a vital part in helping to recruit more psychiatrists.
The primary aim of our study was to determine the attitudes of UK medical students towards different specialties as career options, and to ascertain the position of psychiatry among the specialties.

Method
The King's College research and ethics committee approved the study. Students at Guy's, King's and St Thomas' School of Medicine completed a questionnaire after signing a consent form. The students were given the questionnaires prior to lectures after a brief announcement introducing the study: no reference was made to psychiatry. A count of the number of students was made in order to calculate the response rate. The questionnaires were collected at the end of the lectures. Students belonging to each of the five undergraduate years of the school were approached.
The initial part of the questionnaire gathered general information, including age, gender and year of medical training. Anonymity was maintained by not asking for the students' names. The next section of the questionnaire was directed at the attitudes of medical students towards different specialties as career options. Psychiatry was mentioned in alphabetical order along with the other specialties. It was not mentioned anywhere else, either in the questionnaire or in the information sheet or consent form, in order to avoid bias by suggestion. In this way, our study was unique: all previous studies on this subject mentioned psychiatry explicitly. The students were asked to specify which specialty ('choice') they would like to pursue, and which specialty ('non-choice') they would not consider pursuing as a career; a list of nine options was given to choose from. This was another important improvement in our study over previous studies: we felt that the net difference (choice minus non-choice) would be a much better indicator of the popularity of a specialty than just the percentage of students expressing a preference for it. In addition, there was an option of 'undecided'.
Students were asked the reasons for their respective choices. They were also asked for any personal or family experience of 'physical health problems' and 'mental health problems', in that order.
The data were analysed using the Statistical Package for the Social Sciences (SPSS version 11.0); P50.05 was considered to be statistically significant. A prior power Rajagopal et al Psychiatry as a career choice original papers calculation estimated that a sample size of 300 would have 80% power in detecting small effect sizes.

Results
The questionnaire was completed by 301 students, giving a response rate of 52%. Table 1 gives an analysis of the respondent group by gender and year of study. Table 2 gives the group's response to the different specialties as career choices, career non-choices and the net score (choice minus non-choice) for each specialty.
General surgery/surgical sub-specialties was the most common choice, followed closely by paediatrics. Among non-choices, general surgery/surgical subspecialties was again the most frequent option selected by the students, followed by psychiatry. Looking at the net score (choice minus non-choice), paediatrics achieved the highest positive score, while psychiatry along with research scored the lowest, with a negative percentage of 15.3%.
Exploring the reasons for not choosing psychiatry, the following answers were prominent: 'boring', 'unscientific', 'depressing', 'stressful', 'frustrating' and 'did not enjoy rotation' (in that order). Table 3 compares students choosing psychiatry with those who did not in relation to family history of mental illness. A family history of mental illness is significantly associated with choosing psychiatry. There was no significant difference between choosing psychiatry and choosing other specialties based on age, gender, year of study or personal history of mental illness.

Discussion
Considering the medical students were offered no incentive, financial or otherwise, we feel that 52% was a healthy response rate. The rate was consistent across the year groups, and the male-female distribution was similar to the overall student population.
Clearly, psychiatry continues to be an extremely unpopular specialty among medical students. In this survey, completed by students from a London medical school, it was the least sought-after clinical specialty. The reasons given by the students for not choosing psychiatry show that there are still misconceptions about this specialty. An interesting finding is that a family history of mental illness is associated with choosing psychiatry. Perhaps the experience of knowing or caring for a mentally ill person makes the student more comfortable with psychiatry and psychiatric patients. It could also be that these students have had first-hand experience of the shortcomings in the way psychiatric services are delivered, and therefore want to make a difference. In our study, only nine students expressed a preference for a career in psychiatry. This small sample could be a reason why no other significant difference was detected in relation to other factors associated with choosing psychiatry. A larger study involving a number of medical schools might produce further interesting results. The study's finding suggests that the shortage of psychiatrists is unlikely to be overcome in the near future, and definitely not from the pool of UK-trained medical students. Brockington & Mumford (2002), reviewing the issue of recruitment in psychiatry, estimated that 250-300 consultant psychiatrists are required annually, including replacements and new posts. The same study mentions that 3614 doctors qualify each year in the UK. In our study 3% opted for a career in psychiatry. If this is extrapolated to the whole of the nation, it shows that there is a shortfall of between 140 and 190 psychiatrists every year. Such a persistent shortage has serious implications for the way in which the reforms in psychiatric services, for example those in relation to the National Health Service plan, are implemented in practice. Furthermore, the relationship between psychiatrists and other specialists will continue to be hampered by the poor understanding of mental illness shown by the latter.   consider undertaking a campaign similar to the 'Changing Minds' initiative to destigmatise psychiatry in the eyes of the medical students and doctors belonging to other specialties. Finally, it is important that detailed studies, both quantitative and qualitative, are conducted in order to investigate further the attitude of medical students towards psychiatry.

Declaration of interest
None.