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A survey of foundation doctors' attitudes towards psychiatry before and after their first clinical working year.

Background

Global recruitment in psychiatry has been falling for several decades because medical students and graduates have been finding it consistently unattractive (1,2). An analysis of the career choices of newly qualified doctors in the United Kingdom (U.K.) found the same trend from 1974 to 2009; psychiatry was the first career choice for only 3-5% of medical graduates annually (3). In the U.K., lack of recruitment into psychiatry had reached a crisis point by 2003 when 15% of all unfilled consultants posts in England were in psychiatry and the Royal College of Psychiatrists was finding recruitment into specialist psychiatry posts increasingly difficult (4,5). In 2012, only 78% of the Core Training year one (CT1) posts in psychiatry were filled; a serious shortfall which was overcome by overseas recruitment up until changes in immigration rules.

The factors that seem to dissuade medical students from taking up psychiatry as a future career may include: stigma, bad prognosis of psychiatric disorders, poor scientific base of psychiatry, 'bad-mouthing' from medical colleagues, lack of respect among peers & public, threats of violence from patients and lack of resources (1-5). However, there is evidence to suggest that many students' attitudes towards career choice changed in a positive direction after working in psychiatry due to the perceived 'job satisfaction', 'life-style', 'training available' and 'multidisciplinary approach' (3).

Psychiatry has previously been ranked higher in career choice at the end of students' clinical year (6). To ensure a stable psychiatric workforce for the future, there is an obvious need to motivate current and future cohorts of young doctors to take up psychiatry as a career. Das & Chandrasena (1988) found that attitudes changed positively towards mental health following clinical placement in this specialty (7). It is also known that medical students' attitudes to psychiatry and career intentions can be improved by their experiences of teaching (8). Students were found to develop more positive attitudes when encouraged by senior psychiatrists, had direct involvement in patient care, or saw patients respond well to treatment. Improvement in attitudes during the placement was also related to an increased intention to pursue psychiatry as a career.

Previous research into attitude to psychiatry as a specialty and career choice seems to have produced conflicting results and most of it was carried out among medical students. Since career choices in the U.K. are actually made in the first clinical year following graduation, we carried out a survey among a recent cohort of foundation year one (FY1) doctors in the South East England before and after their first clinical year.

Method

Our study sample consisted of all FY1 doctors (n=101) in one region of South East England. They participated in the study at the beginning and then at the end of their first clinical year. We used a 20--item questionnaire devised by Das & Chandrasena (1988) to ascertain their perceptions and attitudes towards psychiatry before they commenced their first clinical placement. The questionnaire was sent to them via their Medical Education Managers (MEMS). It was handed out to the FY1 doctors as part of their induction pack for completion along with a study information sheet.

At the end of their first year of working, the participants were asked to complete an amended version of the questionnaire. This included two additional questions which ascertained whether the doctor had an opportunity to work in a psychiatric post, or had any experience of psychiatry in practice (such as taster days or cases in A&E). These amended questionnaires were sent to the foundation doctors electronically via their MEMS for completion.

The data was collected and entered into a spreadsheet to prepare descriptive statistics. Comparisons for before and after exposure to psychiatry, and between the psychiatry and nonpsychiatry groups were made using the chi-square test. As the data was binary, a latent class model was developed using LatentGOLD software (9) to explore the associations between different items in the questionnaire. Responses from the questionnaires were coded as: responses which agree with a positive attitude to psychiatry or disagree with a negative attitude were coded as +1; those not sure were coded as 0; and responses which agree with a negative attitude to psychiatry or disagree with a positive attitude were coded as -1.

Results

A 100% (n=101) response rate was obtained for the first set of questionnaires completed at the beginning of the year. However, there was a significant drop in the number of questionnaires completed at the end of the year--a 53.5% response rate (n=54) generally but 61.1% (22 out of 36) for those FY1 doctors who had the opportunity or access to a post in psychiatry within their clinical year.

Initial cohort at beginning of the clinical year vs. those with no exposure to psychiatry at the end

Table 1 shows the group means for each questionnaire item, for the whole cohort at the beginning of the year compared to those with no exposure to psychiatry by the end of the year.

Those FY1 trainees who had not worked in psychiatry during the year were significantly more positive (p = < 0.05) for psychiatry's future, psychiatrist being better at patient communication and not over-medicating their patients. However, they remained significantly less convinced as compared to the whole cohort about psychiatry's intellectual attraction or taking it up as a future career.

Initial cohort at beginning of the year vs. those with exposure to psychiatry at the end

Table 2 shows the group means for each questionnaire item, for the whole cohort at the beginning of the year compared to those with exposure to psychiatry at the end of the year.

After a psychiatry placement, significant positive differences (p=<0.05) were observed in their responses to medical staffs view of psychiatry, future of psychiatry and place of Electro Convulsive Therapy (ECT) in modern medicine. While there was a positive trend in most responses in favour of psychiatry, trainees remained negative about psychiatry's status, its scientific base, curriculum & training and taking up psychiatry as a future career.

Those exposed to psychiatry vs. those not exposed to psychiatry

Table 3 compares responses between FY1 doctors exposed to psychiatry during the clinical year and those who were not.

Those exposed to psychiatry agreed more often that nonpsychiatric medical staffs were critical of psychiatry compared to the group not exposed to psychiatry. They also had comparatively negative responses for psychiatrists not abusing legal powers and to have the legal power to treat someone against their will. Trainees exposed to psychiatry also felt significantly (p=<0.05) positive towards psychiatry being intellectually comprehensive and adopting it as a career. However, they were less enthusiastic about psychiatrists treating patients against their will and psychiatry being the expanding frontier of medicine.

Discussion

In this study, we have ascertained attitudes of a regional cohort of FY1 doctors towards psychiatry as a specialty and as a career choice. Our findings are similar to previous research carried out among medical students, which found that there were generally negative attitudes towards psychiatry as a specialty and career choice but fairly positive attitudes towards the role of psychiatry in medicine and in society in general (1-5,10). Like others, we also found that personal experience of psychiatry placement can improve trainees' view of psychiatry as a specialty and as a future career 311.

It was interesting to find out that after a year in clinical practice but without any experience of psychiatry, trainees' attitudes towards psychiatry as a specialty had been positive. It is difficult to know the exact reason but we can speculate that this respect for the specialty may have developed when they experienced limitations of the other specialties in medicine and/or perhaps due to the positive professional encounters with psychiatrists at the Accident & Emergency (A&E) or with psychiatric liaison teams during ward consultations. As opposed to previous research (11), it was heartening to note that the group with no exposure to psychiatry agreed that non-psychiatric medical staff were not critical of psychiatry; a possible sign of reduced stigma for psychiatry within the medical profession.

Despite exposure to psychiatry, FY1 doctors' attitudes to psychiatry's status, scientific base, curriculum & training and career choice remained somewhat negative. Similar results were found by Lyons et al (11) when they assessed students' attitudes towards psychiatry after a clerkship in the specialty. There was a significant decrease in negative & stigmatising views towards mental illness after the clerkship, but no significant improvement in students' interest in psychiatry was detected (1). Goldacre et al (2013) also acknowledged mixed outcomes of early experience of working in psychiatry as it might discourage some doctors. While highlighting positive effect of the doctors' experience of the speciality, they also cited it as a negative factor that influenced some doctors who had previously considered psychiatry as a career (3).

Our study has limitations because of having a small sample and being carried out in one small region of the country. It is also worth mentioning that the group exposed to psychiatry may not have had a psychiatry placement as it also included those who had had taster days or experience in A&E. The brevity of these latter exposures cannot give someone a real sense of the specialty. The nature of this and the overall experience needs to be differentiated and the exposure quantified in the future studies. Our study findings also need to be replicated with future cohorts and in other regions for confirmation because FY training programme in the U.K. is relatively recent and placements in psychiatry have evolved (4) over the last few years through closer collaboration between different stakeholders in the Foundation Training Programmes.

Competing Interests

None declared

Author Details

DR M AAMER SARFRAZ, Consultant Psychiatrist & Director of Medical Education, Elizabeth Raybould Centre, Bow Arrow Lane, Dartford DA2 6PB. DR INDIA MERRONY, FY2, Elizabeth Raybould Centre, Bow Arrow Lane, Dartford DA2 6PB. CAROL ATKINS, Medical Education Manager, Medway Maritime Hospital, Windmill Road, Gillingham ME7 5NY.

CORRESPONDENCE: DR M AAMER SARFRAZ, Consultant Psychiatrist & Director of Medical Education, Elizabeth Raybould Centre, Bow Arrow Lane, Dartford DA2 6PB.

Email: masarfraz@aol.com

References

(1.) Farooq, K., Lydall, G., Malik, A., Bhugra, D. Why medical students choose psychiatry--a 20 country cross-sectional survey. BMC Med Educ. 2014; 14: 12.

(2.) Fazel, S. & Ebmeier, K. P. Specialty choice in UK junior doctors: is psychiatry the least popular specialty for UK and international medical graduates? BMC Med Educ. 2009 Dec 24;9:77.

(3.) Goldacre M., Fazel, S., Smith, F., Lambert, T. Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009. Brit J Psychiat. 2013; 202:228-34

(4.) Brown, T. Recruitment Strategy 2011-2016 (updated February 2012). Royal College of Psychiatrists, 2012

(5.) Mukherjee, K., Maier, M., Wessely, S. UK crisis in recruitment into psychiatric training. DOI: 10.1192/pb.bp.112.040873 Published 3 June 2013.

(6.) Gowans, M. C., Glazier, L., Wright, B. J., Brenneis, F. R., Scott, I. M. Choosing a Career in Psychiatry: Factors Associated With a Career Interest in Psychiatry Among Canadian Students on Entry to Medical School. Canadian Journal of Psychiatry54.8 (Aug 2009): 557-64.

(7.) Das, M., P., & Chandrasena, R., D. Medical students' attitude towards psychiatry. Can J Psychiatry. 1988; 33(9): 783-7.

(8.) Alexander D.A. & Eagles J. M. Attitudes of men and women medical students to psychiatry. Med Educ. 1986; 20(5):449-55.

(9.) LatentGOLD[R], Statistical Innovations, 375- Concord Avenue, Belmont, MA 02478-3084.

(10.) McParland, M., Noble, M. L., Livingston, G., Manus, C. Medical Education 2003; 37:447-454.

(11.) Stuart, H., Sartorius, N., Liinamaa, T. Images of psychiatry and psychiatrists. Acta Psychiatr Scand. 2015 Jan; 131(1): 21-28.

(12.) Lyons, Z. & Janca, A. Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry as a career choice. BMC Med Educ. 2015 Mar 7;15:34.

This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Table 1: All FY1 doctors before training placements started (initial
cohort) versus FY1 doctors without a psychiatric post after FY1
training

                                 Before    After     Difference

Within medicine, psychiatry      -0.686    -0.591    0.095
has a high status

I may consider pursuing a        -0.539    -0.136    0.403
career in psychiatry in the
future

Psychiatry is attractive         -0.500    0.273     0.773
because it is intellectually
comprehensive

Most non-psychiatric medical     -0.431    -0.500    -0.069
staff are not critical of
psychiatry

Physicians do not have time to   -0.294    0.273     0.567
deal with patients emotional
problems

Psychiatrists understand and     -0.127    0.364     0.491
communicate better than other
physicians

Psychiatrists don't              0.147     0.364     0.217
overanalyse human behaviour

Expressing an interest in        0.157     -0.136    -0.293
psychiatry is not seen as odd

Hospitalised patients are not    0.167     0.591     0.424
given too much medication

Psychiatrists don't make less    0.255     0.045     0.209
money on average than other
physicians

Psychiatry is a rapidly          0.363     0.727     0.365
expanding frontier of medicine

Psychiatric curriculum and       0.520     0.682     0.162
training are not too easy

Psychiatrists are not fuzzy      0.578     0.818     0.240
thinkers

Psychiatrists should have the    0.608     0.955     0.347
legal power to treat patients
against their will

A placement in psychiatry can    0.618     0.864     0.246
change one's negative views of
psychiatry

Psychiatry is scientific and     0.627     0.818     0.191
precise

There is a place for ECT in      0.755     0.727     -0.028
modern medicine

Psychiatric consultations are    0.853     0.864     0.011
often helpful

Entering psychiatry is not a     0.873     1.000     0.127
waste of a medical education

Psychiatrists don't often        0.892     1.000     0.108
abuse their legal powers

                                 L         U         p-value

Within medicine, psychiatry      -0.169    0.359     0.476
has a high status

I may consider pursuing a        0.046     0.760     0.028
career in psychiatry in the
future

Psychiatry is attractive         0.436     1.000     0.000
because it is intellectually
comprehensive

Most non-psychiatric medical     -0.442    0.305     0.717
staff are not critical of
psychiatry

Physicians do not have time to   0.142     0.991     0.009
deal with patients emotional
problems

Psychiatrists understand and     0.090     0.892     0.017
communicate better than other
physicians

Psychiatrists don't              -0.200    0.633     0.306
overanalyse human behaviour

Expressing an interest in        -0.727    0.141     0.184
psychiatry is not seen as odd

Hospitalised patients are not    0.116     0.732     0.007
given too much medication

Psychiatrists don't make less    -0.537    0.118     0.208
money on average than other
physicians

Psychiatry is a rapidly          0.033     0.696     0.032
expanding frontier of medicine

Psychiatric curriculum and       -0.112    0.436     0.243
training are not too easy

Psychiatrists are not fuzzy      -0.082    0.561     0.142
thinkers

Psychiatrists should have the    0.051     0.642     0.022
legal power to treat patients
against their will

A placement in psychiatry can    -0.066    0.558     0.121
change one's negative views of
psychiatry

Psychiatry is scientific and     -0.098    0.480     0.194
precise

There is a place for ECT in      -0.239    0.184     0.797
modern medicine

Psychiatric consultations are    -0.210    0.231     0.924
often helpful

Entering psychiatry is not a     -0.048    0.303     0.153
waste of a medical education

Psychiatrists don't often        -0.049    0.264     0.175
abuse their legal powers

Table 2: All FY1 doctors before training placements started versus
FY1 doctors with a psychiatric post during FY1
training

                                 Before    After     Difference

Within medicine, psychiatry      -0.686    -0.745    -0.058
has a high status

I may consider pursuing a        -0.539    -0.617    -0.078
career in psychiatry in the
future

Psychiatry is attractive         -0.500    -0.468    0.032
because it is intellectually
comprehensive

Most non-psychiatric medical     -0.431    0.106     0.538
staff are not critical of
psychiatry

Physicians do not have time to   -0.294    -0.383    -0.089
deal with patients emotional
problems

Psychiatrists understand and     -0.127    -0.085    0.042
communicate better than other
physicians

Psychiatrists don't              0.147     0.340     0.193
overanalyse human behaviour

Expressing an interest in        0.157     0.106     -0.050
psychiatry is not seen as odd

Hospitalised patients are not    0.167     0.362     0.195
given too much medication

Psychiatrists don't make less    0.255     0.404     0.149
money on average than other
physicians

Psychiatry is a rapidly          0.363     0.064     -0.299
expanding frontier of medicine

Psychiatric curriculum and       0.520     0.596     0.076
training are not too easy

Psychiatrists are not fuzzy      0.578     0.596     0.017
thinkers

Psychiatrists should have the    0.608     0.532     -0.076
legal power to treat patients
against their will

A placement in psychiatry can    0.618     0.574     -0.043
change one's negative views of
psychiatry

Psychiatry is scientific and     0.627     0.702     0.075
precise

There is a place for ECT in      0.755     0.511     -0.244
modern medicine

Psychiatric consultations are    0.853     0.745     -0.108
often helpful

Entering psychiatry is not a     0.873     0.808     -0.064
waste of a medical education

Psychiatrists don't often        0.892     0.766     -0.126
abuse their legal powers

                                 L         U         p-value

Within medicine, psychiatry      -0.242    0.125     0.531
has a high status

I may consider pursuing a        -0.332    0.177     0.547
career in psychiatry in the
future

Psychiatry is attractive         -0.214    0.278     0.798
because it is intellectually
comprehensive

Most non-psychiatric medical     0.248     0.827     0.000
staff are not critical of
psychiatry

Physicians do not have time to   -0.401    0.224     0.575
deal with patients emotional
problems

Psychiatrists understand and     -0.260    0.345     0.783
communicate better than other
physicians

Psychiatrists don't              -0.123    0.510     0.229
overanalyse human behaviour

Expressing an interest in        -0.378    0.277     0.761
psychiatry is not seen as odd

Hospitalised patients are not    -0.044    0.434     0.109
given too much medication

Psychiatrists don't make less    -0.092    0.391     0.224
money on average than other
physicians

Psychiatry is a rapidly          -0.569    -0.029    0.030
expanding frontier of medicine

Psychiatric curriculum and       -0.128    0.281     0.464
training are not too easy

Psychiatrists are not fuzzy      -0.233    0.268     0.892
thinkers

Psychiatrists should have the    -0.323    0.171     0.545
legal power to treat patients
against their will

A placement in psychiatry can    -0.290    0.203     0.730
change one's negative views of
psychiatry

Psychiatry is scientific and     -0.155    0.304     0.521
precise

There is a place for ECT in      -0.427    -0.061    0.009
modern medicine

Psychiatric consultations are    -0.289    0.073     0.239
often helpful

Entering psychiatry is not a     -0.218    0.090     0.412
waste of a medical education

Psychiatrists don't often        -0.279    0.027     0.105
abuse their legal powers

Table 3: FY1 doctors who had a psychiatric post versus those who
did not have one

Sorted by the size of the
difference between the two
groups.

                             Psychiatry   No           Difference
                                          Psychiatry

Most non-psychiatric         0.106        -0.500       -0.606
medical staff are not
critical of psychiatry

Psychiatrists don't make     0.404        0.045        -0.359
less money on average than
other physicians

Expressing an interest in    0.106        -0.136       -0.243
psychiatry is not seen as
odd

Psychiatrists don't          0.340        0.364        0.023
overanalyse human
behaviour

Psychiatric curriculum and   0.596        0.682        0.086
training are not too easy

Psychiatry is scientific     0.702        0.818        0.116
and precise

Psychiatric consultations    0.745        0.864        0.119
are often helpful

Within medicine,             -0.745       -0.591       0.154
psychiatry has a high
status

Entering psychiatry is not   0.808        1.000        0.191
a waste of a medical
education

There is a place for ECT     0.511        0.727        0.217
in modern medicine

Psychiatrists are not        0.596        0.818        0.222
fuzzy thinkers

Hospitalised patients are    0.362        0.591        0.223
not given too much
medication

Psychiatrists don't often    0.766        1.000        0.234
abuse their legal powers

A placement in psychiatry    0.574        0.864        0.289
can change one's negative
views of psychiatry

Psychiatrists should have    0.532        0.955        0.423
the legal power to treat
patients against their
will

Psychiatrists understand     -0.085       0.364        0.449
and communicate better
than other physicians

I may consider pursuing a    -0.617       -0.136       0.481
career in psychiatry in
the future

Physicians do not have       -0.383       0.273        0.656
time to deal with patients
emotional problems

Psychiatry is a rapidly      0.064        0.727        0.663
expanding frontier of
medicine

Psychiatry is attractive     -0.468       0.273        0.741
because it is
intellectually
comprehensive

Sorted by the size of the                      t-test    ranksum
difference between the two
groups.

                             L        U        p-value   p-value

Most non-psychiatric         -1.000   -0.144   0.011     0.011
medical staff are not
critical of psychiatry

Psychiatrists don't make     -0.694   -0.024   0.036     0.034
less money on average than
other physicians

Expressing an interest in    -0.735   0.249    0.329     0.322
psychiatry is not seen as
odd

Psychiatrists don't          -0.421   0.467    0.917     0.907
overanalyse human
behaviour

Psychiatric curriculum and   -0.210   0.382    0.564     0.497
training are not too easy

Psychiatry is scientific     -0.187   0.419    0.447     0.777
and precise

Psychiatric consultations    -0.173   0.411    0.419     0.388
are often helpful

Within medicine,             -0.130   0.437    0.283     0.391
psychiatry has a high
status

Entering psychiatry is not   -0.020   0.403    0.075     0.058
a waste of a medical
education

There is a place for ECT     -0.117   0.551    0.200     0.192
in modern medicine

Psychiatrists are not        -0.114   0.559    0.192     0.190
fuzzy thinkers

Hospitalised patients are    -0.139   0.597    0.218     0.192
not given too much
medication

Psychiatrists don't often    -0.005   0.473    0.055     0.040
abuse their legal powers

A placement in psychiatry    -0.045   0.623    0.088     0.064
can change one's negative
views of psychiatry

Psychiatrists should have    0.097    0.748    0.012     0.011
the legal power to treat
patients against their
will

Psychiatrists understand     0.000    0.897    0.050     0.050
and communicate better
than other physicians

I may consider pursuing a    0.084    0.878    0.028     0.017
career in psychiatry in
the future

Physicians do not have       0.195    1.000    0.006     0.007
time to deal with patients
emotional problems

Psychiatry is a rapidly      0.269    1.000    0.001     0.002
expanding frontier of
medicine

Psychiatry is attractive     0.352    1.000    0.000     0.001
because it is
intellectually
comprehensive
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Author:Sarfraz, M Aamer; Merrony, India; Atkins, Carol
Publication:British Journal of Medical Practitioners
Article Type:Survey
Date:Sep 1, 2016
Words:3843
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