INTRODUCTION

Steering the most successful medical students towards the field of psychiatry is becoming a major goal in United States and in many other countries (1). Although psychiatrists themselves do not care about whether there is a problem in “steering towards the field of psychiatry” or not, some common features in people who have chosen this field were determined in some studies such as being older, having less scientific mentality but being more empathetic and having better verbal skills (2,3). In some prospective studies, opinion of medical students on the field of psychiatry gave conflicting results (4,5). For example, medical students having positive opinions found psychiatry valuable and beneficial; however, they also related this field with lower respect and income (4), patients that were not adequately recovered and family opinions of lower grade career (2,6). Actually, approximately 95% of medical students choose a specialty other than psychiatry (7). In a recent study, it was found that students who preferred psychiatry as a career considered two factors important. According to this study internal factors (e.g., quality of psychiatry training) were the most important factors; however, external factors (e.g., tendency among physicians, geographical location) were given less importance (8). It seems to be duty of psychiatry trainers to balance raising interest to psychiatry residency and giving adequate psychiatry training. Attitudes of medical students towards psychiatry residency have never been studied in our country. Due to this reason, it is not known what the current situation is. The purpose of this study is to investigate and compare the attitudes of students from medical schools in Istanbul and Afyonkarahisar provinces whom were preparing to specialty examination.

METHODS

Students who were in the sixth (last) year of the medical schools of Istanbul University and Afyon Kocatepe University or recently graduated from one of these schools and were preparing to specialty examination were included to the study. Students who were preparing to the exam at the libraries of these medical schools were contacted and were informed about the study. A hundred students from Istanbul did not want to participate in the study due to their time constraints. All students from Afyon agreed to participate. Students who entered to more than one exam (older graduates) and physicians already started their practice were excluded from the study. After the informed consents of participants were taken, sociodemographic questionnaire was given. After that, a 39-item questionnaire prepared by our team which was designed to investigate the factors affecting specialty preference and attitude of students towards psychiatry residency was given. Five choices were in the questionnaire (fully disagree, disagree, neutral, agree and fully agree). When findings were transferred to statistics software, “disagree” and “fully disagree” responses and “agree” and “fully agree” responses were combined. The study complied with Helsinki Declaration criteria and local ethics committee approval of Istanbul University was taken. Data were recorded and processed by SPSS 13.0 software. Frequency analysis of data was done subsequently. Student’s t test and Chi-square tests were used to compare data from both groups. Statistical significance value was pre-determined as p<0.05.

RESULTS

One hundred and thirty-seven medical students were participated in the study. Participants were 24.42±1.59 years old (24.53±1.80 from Istanbul and 24.17±0.86 from Afyonkarahisar, p=0.22). 70.1% (n=97) of participants were from Istanbul and remaining 29.9% (n=40) were from Afyonkarahisar. Participants preparing for specialty exam were 96 men and 61 women and 120 at last year of the school; only 17 participants were recently graduated (all were settled in Istanbul). Forty-two of them received psychiatric treatment but 95 of them have never received psychiatric care. The first four most favorite specialties were ear-nose-throat (27.7%), ophthalmology (23.3%), internal medicine (20.5%) and cardiology (20.4%). Prevalence of choosing psychiatry as one of the most three favorite specialties was 18.2%. The most unattractive specialties were as follows: general surgery (43.0%), physical therapy and rehabilitation (26.3%), internal medicine (24.9%). Prevalence of finding psychiatry unattractive was 16%. The most respected ones among all medical specialties were cardiology (31.4%) and plastic surgery (16.1%). Belief in respect of psychiatry specialty was 0.7% (n=1). Specialties which were believed to be with the highest incomes were obstetrics and gynecology (57.7%) and plastic surgery (10.9%) but this proportion was only 0.7% (n=1) for psychiatry. Specialties which were believed to be with the lowest incomes were basic medical sciences (27.8%) and neurology (16.0%). No one believed that obstetrics and gynecology and cardiology were with low income and this proportion was 2.9% for psychiatry. “Makes me earn more” alternative was agreed by 50.3% and disagreed by 21.2% of the participants. “Reason to prefer was less shift duties” was agreed by 69.4% and disagreed by 18.2% of participants. Geographical location of the job in choosing the specialty was found to be important by 75.9% and not found to be important by 12.4%. Believing in patients’ benefit from treatment in choosing the specialty was found to be important by 81.8%. Specialties believed to be most beneficial for patients’ problems were general surgery (41.6%) and obstetrics and gynecology (10.2%). Only 1.5% of the participants believed that psychiatric patients get benefit from their treatments. Eighty-nine percent of the participants thought that physicians’ exposure to violence is independent of the specialty. Points of concern in career planning and answers searching attitudes of students preparing to specialty exam are summarized in table 1 (Table 1).

One of the questions investigated with a focus on psychiatry career was “thinking psychiatry as a career” and 27.0% answered as “possible” and 43.8% answered “not possible”. Participants whom found this specialty less prestigious and less respectful compared with other specialties was found 12.4% and 64.9% was found to think the opposite. Rate of finding psychiatry financially satisfying was 50.3%. “On should be in a big city if he/she choose psychiatry as a career” statement was agreed by 69.3% of the participants but disagreed by 8.8%. Psychiatry was described as “having insufficient scientific basis” and “mostly a social specialty” by 43.1% of participants. Fifty-four percent of the participants said that they will feel themselves less competent against psychiatric patients and diseases compared to other specialties. On the other hand, 60.8% of the participants believed that understanding human behavior and dealing with personalities make psychiatry attractive. However, 61.3% thought that treatment of psychiatric diseases is difficult and possibility of cure is low. 48.2% of participants preparing for specialty exam said that they will not choose psychiatry residency due to its high dependency to individual characteristics. More than 60% of participants believed that psychiatry career leads to get more involved in nonsense things and dealing more with value judgments and religion. “Only sex is spoken in psychiatry practice” statement was agreed only by 2.2%. Conditions which medical students whom were resident candidates considered as important and their answers to the questions asking their attitudes were given in table 2, 3 and 4 (Table 2,3,4).

There were no significant differences between students whom were being trained in Istanbul and Afyonkarahisar and were preparing to specialty exam in terms of age, place and date of birth, location of previous life, gender, family style, family’s income level and previous psychiatric care. Students from Istanbul gave more importance to “less shift duties” and “less tiredness” in choosing the specialty compared to students from Afyonkarahisar (χ2=7.79; p=0.023). More students from Istanbul thought that “Big city is important for psychiatry training” (χ2=16.19; p<0.001). Moreover, more students from Istanbul agreed with the idea of being exposed to violence at all specialties (χ2=17.67; p<0.001). Also, more students from Istanbul were thinking that psychiatric disorders are of longer duration, difficult to treat and less responsive to treatment (χ2=7.77; p=0.023). More students from Istanbul believed that “being a psychiatry resident will be perceived as a failure by their families” (χ2=7.32; p=0.026). Significantly higher number of more students from Afyonkarahisar stated that “pharmaceutical industry support is important in psychiatry” (χ2=9.74; p=0.008).

Attitudes of participants to psychiatry residency were also evaluated according to genders as well. Male students tend to choose specialties which they will earn higher more than female students (χ2=14.10; p=0.001). Female students were thinking that they can feel themselves weak against psychiatric patients and disorders (χ2=8.84; p=0.012). Instead of this, some of the female students said that they did not think psychiatry career due to possible exposure to violence by psychiatric patients (χ2=13.01; p<0.001).

DISCUSSION

Several countries investigated the tendency of medical students to choose psychiatry as a career and in the last 30-40 years choosing psychiatry tended to be lower (9). Medical students worldwide stated that a more controllable life style (less time consuming, private practice) and possibilities to help patients are important in residency choices but they have conflicting ideas about prestige or financial satisfaction (4,10). In our study, two thirds of participants gave importance to less shift duties and three fourths of them gave importance to work in a city by the sea, closer to big cities or having milder climate. In our study, significantly more students from Istanbul believed in the importance of less shift duties and getting less tired. Istanbul is a city which industrialization and running hither and yon is much more intense than Afyonkarahisar. Desire of students from Istanbul to have a more controllable and comfortable life may be due to these characteristics of Istanbul. Nevertheless, our findings suggest that medical students give more importance to professional characteristics which they can better control qualitatively. However, this comfort approach leaves itself to different expectations when professional training and skills are considered. Because, in our study seven out of ten participants found “If I choose psychiatry specialty, I have to be trained in big cities” statement as important. Education and living in a big city has not ever been discussed in the scientific literature. However, well-trained psychiatrists and trainers (e.g., various psychotherapies) generally work at big cities with a few exceptions.

In a study, it was found that students believe psychiatry specialty earns less than ob &gyn and general surgery but more than internal medicine and pediatrics (1). In our study, specialties which are believed to earn most were ob & gyn and plastic surgery and only one participant stated psychiatry as earning the most. Moreover, 50% of the students said that higher income is important in choosing the specialty. Nevertheless, rate of having psychiatry in the first three choices was 18%. This finding supports the importance of prestige and income by medical students but these were not enough to determine the choice of specialty. In the study of Abramowitz and Bentov-Gofrit (1), psychiatry was among the less prestigious specialties with internal medicine and ob & gyn. In our study, the most prestigious specialties were cardiology and plastic surgery and only one participant stated psychiatry as the most prestigious. Significantly more students from Istanbul thought that psychiatry residency will be perceived as low success by their families. In two other studies, low success perception of psychiatry specialty by families were also mentioned (11,12). Specialty exam scores of Istanbul medical schools are higher than Afyon Kocatepe University Medical School. Moreover, training in medical schools of big cities is perceived as a more successful action by the society and families. These two conditions might have influenced the perception of medical students from Istanbul.

Giving importance to “Helping patients” in choosing the specialty was 81.8% in our study and this was one our most important findings. However, only 1.5% of the participants believed that psychiatric patients get benefit from treatment. Additionally, 61.35 of the participants thought that “psychiatric diseases take longer times and can be cured less”. Chronic and inadequately recovered patients lead to confusion in choosing psychiatry (13). However, in another study, students whom seriously thought of choosing psychiatry during their medical education believed that patients respond well to treatment compared to students whom did not thought of. In order to overcome this problem, efficacy of psychotropic drugs and psychotherapy should be better explained to the students (7,14). Also, clinical experience in child psychiatry and closer contact of students with patients during the internship may help them to observe the “real world” setting better. As expected, students only having contact with inpatients will continue to believe that psychiatric patients are untreatable and incurable (7,14). Also, interns whom will see consultation and liaison practices and their consequences may increase their acceptance of the efficacy of psychiatric treatments. Hopeless view about psychiatric diseases was significantly higher among students from Istanbul. Rotation periods in Afyon Kocatepe University consist of 4-6 students but in Istanbul University this number is about 30-50. With such a high number, it will be difficult to evaluate psychiatric patients and consequences of treatment in Istanbul University. Also, more students from Istanbul are traditionally trained in inpatient clinic and outpatients are seen less. Another possible reason is the preference of big cities by treatment- resistant psychiatry patients as the last resort and higher contact of students with these kinds of patients.

In our study, one out of every two or three medical student thought themselves ineffective, stressful and inadequate against psychiatric patients. Feeling restless with psychiatric patients (4), stressful feeling of interns with psychiatric patients (2), and feeling of interns who think psychiatry as a specialty being challenged against psychiatric patients and who do not think psychiatry as “restricted” (15) are problematic areas which were mentioned frequently in the scientific literature. New training methods which will not put stress on interns and make them feel competent and efficient should be found. Also, it should be reminded to every intern that a piece of stress is inevitable in psychiatry like in other rotations (16,17). However, it should be kept in mind that time spent with patients should not be reduced and psychiatry rotation should not be perceived as an “easy rotation” in order to reduce the stress (15).

When psychiatry residents and students are considered together, possibility of being exposed to violence increase to 90% (18) and it was proposed that this may have a negative impact to choose psychiatry as a career (19). Proportion of students who think that exposure to violence/assault by psychiatric patients make them away from choosing psychiatry was 16% in our study and did not support this proposal. This may be due to the high prevalence (89%) of students finding “being a physician is related with exposure to violence independent of the specialty” and become inured to violence towards physicians in our country. More students from Istanbul accepted being exposed to violence as an ordinary event. This may be due to Istanbul being a metropolitan city which violent incidents exist more. The main restriction of our study is the low number of participants. In addition to this, our data were obtained by a cross-sectional study. However, it was proposed that specialty preferences of medical students may change over time (2,20). Another restriction is that our study is based on questionnaire fulfillment and self-reported data. In this kind of self-reported studies, more socially acceptable responses may sometimes have been given.

In conclusion, our study is important because it is the first study which investigated what medical students paid attention to when choosing a specialty and their opinions about psychiatry residency. It was understood that students not only give importance to helping patients but consider residencies which offer more controllable life styles. Provinces of medical education were also influenced students’ choices.

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