Familiarity breeds respect: attitudes of medical students towards
psychiatry following a clinical attachment
Lisa Lampe, Carissa Coulston, Garry Walter and Gin Malhi
Senior Lecturer, Discipline of Psychiatry, University of Sydney; Staff Specialist (Academic) Northern Sydney
Central Coast Area Health Service; Consultant Psychiatrist, CADE Clinic, Department of Academic Psychiatry,
Royal North Shore Hospital, NSW, Australia
Clinical Senior Lecturer and Clinical Psychologist, Discipline of Psychiatry, University of Sydney; and CADE Clinic,
Department of Academic Psychiatry, Royal North Shore Hospital, NSW, Australia
Professor of Child and Adolescent Psychiatry, Discipline of Psychiatry, University of Sydney; Area Clinical
Director, Child and Adolescent Mental Health Services, Northern Sydney Central Coast Area Health Service,
NSW, Australia; and Adjunct Professor, Department of Psychiatry, Dalhousie University, Halifax, Canada
Chair of Psychiatry and Head, Discipline of Psychiatry, University of Sydney; and Director, CADE Clinic,
Department of Academic Psychiatry, Royal North Shore Hospital, NSW, Australia.
Correspondence: Dr Lisa Lampe, CADE Clinic, Department of Academic Psychiatry, Level 5, Building 36, Royal
North Shore Hospital, St Leonards, Sydney, NSW, 2065, Australia. Phone: +61 2 9926 7746; Fax: +61 2 9926
7730; e-mail: firstname.lastname@example.org
To examine the influence of a clinical attachment in psychiatry on medical
students’ attitudes to psychiatry as a specialty and potential career.
Medical students were surveyed following an eight week clinical attachment in
psychiatry. Secondary analyses sought to identify associations with variables
such as age, gender and level of clinical experience as a medical student.
Following a clinical attachment in psychiatry, 80% of students rated their
attitude to psychiatry as more positive. Approximately 32% rated themselves
as likely or very likely to choose a career in psychiatry. No differences were
seen with respect to gender, age or stage of training. The quality of the
teaching, enthusiasm of clinical teachers, holistic approach and scientific
basis of psychiatry were cited by students as factors influencing attitudes.
The clinical rotation in psychiatry is a significant factor influencing medical
student attitudes towards psychiatry.
Medical students, psychiatry, teaching.
What are the goals of teaching psychiatry to medical students? Psychiatric
disorders are common, costly and carry a high disease burden. Effective
treatments are available and early intervention can prevent disability.
Therefore, we might reasonably expect students to graduate from their clinical
attachments in psychiatry with the ability to recognise common mental
disorders and initiate, or refer for, evidence-based treatments. In order to take
an adequate history that will enable a diagnosis to be made, we expect
students to develop skills in communicating with patients, thereby eliciting
symptoms of psychiatric distress and recognising important signs in the
mental state. Yet, arguably, the goals of a clinical attachment in psychiatry
should be broader and more ambitious. With a world wide shortage of
psychiatrists, we might also hope that, as a result of a clinical attachment in
psychiatry, some students might be inspired to consider psychiatry as a
THE INFLUENCE OF CLINICAL ATTACHMENTS ON ATTITUDES TO
PSYCHIATRY AND CAREER CHOICE
The percentage of medical students entering psychiatry has been gradually
dropping from a post World War II high of about 7% (Eagle and Marcos 1980;
Sierles and Taylor 1995) to 3-4% (Nielsen 1980; Feifel, Moutier et al. 1999;
Brockington and Mumford 2002; Sierles, Dinwiddie et al. 2003). The factors
associated with medical student attitudes to psychiatry and choosing a
psychiatry career have been examined in a large number of studies (eg
(Eagle and Marcos 1980; Ney, Tam et al. 1990; Feifel, Moutier et al. 1999;
Malhi, Parker et al. 2002; Malhi, Parker et al. 2003; Rajagopal, Rehill et al.
2004; Goldacre, Turner et al. 2005; Cutler, Alspector et al. 2006; Ndetei,
Khasakhala et al. 2008; Wigney and Parker 2008; Gowans, Glazier et al.
2009)) and studies of innovative methods to encourage students to pursue
psychiatry have also been conducted (eg (Robertson, Walter et al. 2009;
Lyons, Power et al. 2010)). A subset of these studies has examined the
influence of clinical attachments.
Following 8 week clinical attachments in psychiatry, the percentage of
students reporting more positive attitudes to psychiatry and a likelihood of
pursuing a psychiatry career rose from 6% to 17% (Wilkinson, Toone et al.
1983), and 19% to 27% (McParland, Noble et al. 2003) respectively. In a
Danish study, the proportion who would ‘consider’ psychiatry increased from
12.7% to 25% following a 4-week attachment (Holm-Petersen, Vinge et al.
2007). A recent German study showed little change in attitude to psychiatry,
but a modest association between a positive perception of a clinical
attachment and increased positive attitude (Kuhnigk, Strebel et al. 2007).
Experience of psychiatry as a medical student was cited as an influence by
doctors in their first post graduate year who had made the decision to
specialize in psychiatry, and was a more important factor in choosing
psychiatry than the medical student experience was in choosing other
specialities (Goldacre, Turner et al. 2005). The medical student experience of
the psychiatry clerkship was the most frequently cited or highest ranked
influence on career choice by psychiatry trainees at various stages of their
careers in two studies (Zimny and Sata 1986; Kirchner and Owen 1996).
Experience in the clinical clerkship was a more important factor for psychiatry
trainees who reported themselves as having had little interest in psychiatry as
a career as medical students prior to their clinical attachment (Manassis, Katz
et al. 2006).
Finally, there is some suggestion in the literature that the number of medical
students considering a career in psychiatry may increase after a clinical
clerkship, then experiences a mild decline, followed by a steady increase in
the years following graduation (Brockington and Mumford 2002; Maidment,
Livingston et al. 2004; Goldacre, Turner et al. 2005).
PSYCHIATRY TEACHING AT SYDNEY MEDICAL SCHOOL
The Sydney Medical School (SMS) offers a four year postgraduate medical
program. Students begin their clinical attachments in year three of the course,
and progress through a total of nine attachments before entering a pre-intern
rotation. Following a curriculum review, a decision was made to reduce the
clinical rotation in psychiatry and addiction medicine from 9 weeks to 8 weeks
and move it from the final year to the third year of the program. This change
was implemented in 2009, with the result that students in both the third and
fourth years completed their rotations in psychiatry concurrently. This provided
an opportunity to study a larger cohort, as well as to examine for differences in
attitudes between students at different stages of the medical course.
At the SMS Northern Clinical Campus, students complete rotations in
psychological and addiction medicine from March to December. With the
combined year 3 and year 4 students, this effectively represented clinical
experience ranging from the second to the ninth (final) clinical attachment as a
student. Students are allocated two consecutive attachments of 3-4 weeks in
different settings, which may include acute adult inpatient psychiatry units in
both public and private hospitals, public outpatient psychiatry clinics in the
community, consultation-liaison services and old age psychiatry. In addition,
students complete a one week placement in a drug and alcohol treatment
service, interacting with both inpatients and outpatients. The type of clinical
rotation has not been shown to be a significant factor in influencing student
attitudes (Bobo, Nevin et al. 2009).
The participants comprised 82 SMS medical students based at the Northern
Clinical Campus who had undertaken the clinical attachment in psychiatry.
The students were currently in stages 3 or 4 of their training, and undertook
the attachment in the 2nd, 3rd, or 4th rotations of the academic year.
Students are routinely asked to complete several feedback surveys through
the course of the year. In order to avoid imposing an additional burden at the
beginning of the rotation, they were asked to make retrospective judgements
at the conclusion of their attachment as an extension of the post rotation
survey. This had the added advantage of not alerting students to the explicit
purpose of the questions. Three questions about attitudes to psychiatry were
added. The students were asked to rate on a Likert scale the likelihood that
they would consider a career in psychiatry, whether this likelihood had
changed since the start of the term, and whether there had been any change
in their attitude to psychiatry as a specialty. There was also a qualitative
question in which the students were invited to nominate any particular
influences on their attitudes. Questionnaires were completed in week 7 of the
8 week rotation.
The collated data was entered into SPSS. Basic descriptive statistics were
extracted, and the frequencies of responses were charted. One-Way Analysis
of Variance (ANOVA) was performed to determine any differences in age
between ratings for considering a career in psychiatry, changes in considering
a career in psychiatry since commencing the attachment, and changes in
attitude to psychiatry. The Kruskal-Wallis Analysis of Variance (ANOVA) and
Mann-Whitney U-Test for non-parametric data was performed to examine
differences between males and females, and students in different stages of
their medical course with respect to considering a career in psychiatry,
changes in considering a career in psychiatry since commencing the
attachment, and changes in attitude to psychiatry. Chi-square tests were
performed to examine the relationship between categorical variables. These
included the likelihood of presently considering a career in psychiatry and any
changes in attitude towards the field of psychiatry.
Of the 82 students, 76 (93%) completed the questionnaire. Students were not
asked to indicate their age on the questionnaires, so age was estimated
according to when they completed their final year of high school (year 12),
and 18 years was taken as the age at which students typically complete year
12. On this basis, the mean age of the sample was 27.96 years (SD=2.78).
In terms of stage and rotation, 11 students (14.5%) were in stage 3 rotation 2,
eight (10.5%) were in stage 3 rotation 3, 12 (15.8%) were in stage 3 rotation
4, 14 (18.4%) were in stage 4 rotation 2, 16 (21.1%) were in stage 4 rotation
3, and 14 (18.4%) were in stage 4 rotation 4. One student (1.3%) did not
specify stage, but was undertaking rotation 2.
The 26 students who were undertaking the attachment in rotation 2 (in both
stages 3 and 4) were not asked to nominate their gender. Of the remaining
50 students, 25 (50%) were male. There was no difference in the proportion
of males and females between stages 3 and 4, and rotations 3 and 4.
Attitudes towards a career in psychiatry
Twenty-seven students (35.5%) rated themselves as neutral regarding the
likelihood of choosing a career in psychiatry, with equally large numbers
identifying themselves as likely (25%) or unlikely (25%), and equally small
numbers identifying themselves as either very likely (6.6%) or very unlikely
(6.6%) (Figure 1). The distribution of ratings was remarkably symmetrical and
approximated to a normal distribution centred on neutrality. There were no
differences between males and females or between students at different
stages of their medical course in terms of likelihood in considering a career in
psychiatry. Further, ratings of likelihood in considering a career in psychiatry
were not related to age.
When asked about perceived change in likelihood to consider psychiatry as a
career since commencement of the attachment, 48.7% of respondents
reported they were more likely (Figure 2) and 19.7% reported they were much
more likely to consider psychiatry as a career. Few students rated themselves
as less likely (7.9%) or much less likely (1.3%). There were no differences
between males and females or between students at different stages of their
medical course in terms of changes in considering a career in psychiatry.
Further, changes in considering a career in psychiatry were not related to age.
With regards to any change in attitude to psychiatry as a speciality, 40.8% of
students rated their attitude as a little more positive and 39.5% rated as much
more positive (Figure 3). Smaller numbers of students rated their attitude as
much more negative (1.3%) and a little more negative (2.6%). There were no
differences between males and females or between students at different
stages of their medical course in terms of changes in attitude to psychiatry.
Further, changes in considering a career in psychiatry were not related to age.
Chi-square tests showed a significant association between degree of change
in considering a career in psychiatry since commencing the attachment and
actual current ratings of likelihood in considering a career in psychiatry
(X2(df=2)=19.62, p<0.001). A total of 52 students (68.4%) rated themselves as
likely or much more likely to consider a career in psychiatry since completing
their clinical attachment. Of these, 38.5% indicated they were currently likely
or very likely to consider a career in psychiatry, while 42.3% indicated that
they were currently neutral in this consideration. The remaining 19.2%,
despite rating themselves as likely or much more likely than prior to the
rotation to consider a career in psychiatry, still regarded themselves as
unlikely or very unlikely. There were seven students (9.2%) who rated
themselves as less or much less likely to consider a career in psychiatry since
completing their clinical attachment, and all seven (100%) indicated they were
currently unlikely or very unlikely to consider a career in psychiatry.
Finally, students were invited to comment on anything that had changed their
attitude to psychiatry; 54 respondents (71%) chose to make comments. A
number of themes emerged in association with positive views of psychiatry
which can be summarised as:
The evidence-based, scientific or structured nature of psychiatry (which
often came as a surprise to students)
Fascinating/interesting/complex area (again, some students commented
that this had come as a surprise to them)
The holistic perspective of psychiatry
Positive view of lifestyle associated with a career in psychiatry
Enthusiasm of teachers in psychiatry (most teaching input came from
psychiatrists and registrars)
Treating the students well; psychiatrists seen as ‘nice’ people
Admired the skill of clinicians
Seeing people get better; ‘how much good you can do’
Enjoyment of working with/talking to people
A small number of students rated themselves as less likely to consider
psychiatry as a career. Negative views of psychiatry appeared to be
influenced by a poor experience of the clinical attachment (e.g. little or poor
teaching, unwelcoming staff), a view of psychiatrists as unhappy, or negative
views more closely pertaining to the nature of the work (eg that it is ‘draining’
or too challenging).
There were also a number of students who commented that they found their
experience in private psychiatry more satisfying than the public system, where
patients seemed to ‘fall through the cracks’ or the system seemed inadequate
for the needs of many patients. Some students felt that, in the private sector,
staff seemed more satisfied and the benefits of intervention for the patient
were more obvious. However, it should be stressed that many students
reported very positive experiences in the public system.
For most students, a clinical attachment in psychiatry was followed by more
positive ratings in their attitude to psychiatry, and an increase in the reported
likelihood that they would consider a career in psychiatry. The proportion
showing a positive increase in attitude to psychiatry is greater than that
reported after students viewed an educational DVD about psychiatry
(Robertson, Walter et al. 2009) and may reflect the greater influence of a
clerkship compared to watching a DVD. A strength of the current study is the
very high response rate compared to most other studies.
In contrast to other studies (Ney, Tam et al. 1990; Malhi, Parker et al. 2002;
McParland, Noble et al. 2003; Goldacre, Turner et al. 2005), we found no
difference between men and women in terms of attitude to psychiatry. Fully a
third of the students who offered explanations for their change in attitudes
cited the quality of the teaching or enthusiasm of their psychiatrist or registrar
teachers, and/or the fact that they were treated well. This accords with other
research showing that positive teaching and learning experiences, and seeing
patients get better, improved student attitudes to psychiatry (Ney, Tam et al.
1990; McParland, Noble et al. 2003). Other commonly cited reasons included
coming to the view that psychiatry was ‘scientific’, ‘fascinating’ and ‘holistic’. In
common with previous research, a view of psychiatry being associated with
high quality of life also appeared to be a significant factor (Goldacre, Turner et
al. 2005; Cutler, Alspector et al. 2006; Wigney and Parker 2008; Robertson,
Walter et al. 2009).
About a third of the students indicated that they were likely to consider a
career in psychiatry. This compares to 25% in a Danish sample with students
of comparable mean age (Holm-Petersen, Vinge et al. 2007). The 6.6% that
rated themselves as ‘very likely’ to consider a career in psychiatry is
comparable to a UK sample in which 4.3% rated themselves post-attachment
as ‘definitely’ wanting to be a psychiatrist (Maidment, Livingston et al. 2004).
In the UK study, the pre-attachment rate was 1.3%, and 5.2% were working in
psychiatry when followed up as senior house officers. These findings suggest
that when a positive attitude towards psychiatry is coupled with an intention to
specialize in psychiatry, this career path is likely to be realized, and
underscores the importance of a positive experience during the attachment as
a key factor promoting the pursuit of a career in psychiatry.
Another interesting finding in the current study is the qualitative responses
that indicate that at least some students viewed psychiatry as having a
scientific basis. This is in contrast to early research in the field, but consistent
with more recent findings (Wigney and Parker 2008; Robertson, Walter et al.
This data suggests that a relatively brief exposure to psychiatry can result in a
significant change in attitude amongst medical students. This seems
applicable to all students irrespective of age, gender or stage of the course,
suggesting that no particular modifications need to be made in the change
from a relatively more senior to more junior timing of the psychiatry
attachment in the medical course.
For a very small number of students, the clinical attachment resulted in a
more negative view, which appeared to be associated either with a negative
teaching experience or discomfort with the nature of psychiatry which became
evident with actual experience. It is possible that personality factors could
account for discomfort with the nature of the discipline, a proposition which
receives some support from the literature (Mowbray, Davies et al. 1990). In
order to reduce the negative impact which the nature of clinical work in
psychiatry has on some students, more attention could be paid to discussing
with students the ways in which psychiatrists develop strategies to cope with
the stress of the job. Qualitative feedback indicated that a lack of enthusiasm
or commitment to teaching by some consultant psychiatrists, the most
influential clinical teachers, was associated with a more negative view of
psychiatry. This represents another potentially modifiable factor (e.g. (Selzer
and Steven (in press))).
As this was a cross-sectional study, there is no evidence that positive
changes in attitude to psychiatry and likelihood of considering it as a career
will persist. Indeed, it is possible that students would rate every speciality
more positively following a clinical attachment. A follow-up rating would
minimise the contribution of proximity bias.
Students were asked to compare their attitudes post attachment to attitudes
prior to the attachment, which may have introduced bias due to the
retrospective nature of making such assessments.
Inclusion of a control group, for example, students yet to complete their
attachment or students from another university, would have strengthened the
These results show the importance of the clinical attachment in changing
attitudes towards psychiatry, and the potential for this to translate into more
doctors considering a career in psychiatry. The importance of a positive
teaching experience, with clinical teachers who are welcoming and
enthusiastic, is especially highlighted. Factors associated with a more
negative view of psychiatry, dysphoria about the nature of the work and
disinterested clinical teachers, are potentially modifiable. Teaching can
represent an additional burden for busy clinicians. However, with the current
severe workforce shortage in psychiatry, one way to reduce the overwork that
results from such shortages might be to maintain the enthusiasm
demonstrated by the majority of teachers, given the associations shown in this
study with more positive attitudes to psychiatry and higher ratings of likelihood
to consider a career in psychiatry that may flow on from positive experiences.
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Australasian Psychiatry, 18(4), August 2010 pp348-353. by SAGE
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