Objectives Given the low recruitment to psychiatry worldwide, the current study aimed to examine how premedical and intramedical school factors, perception of career aspects, attitudes towards psychiatry, stigma towards mental illness and personality traits may affect the likelihood of psychiatry as a career choice.
Design Cross-sectional online study.
Participants 502 medical students from two public medical institutions in Singapore.
Methods We critically examined existing literature for factors identified to influence psychiatry as a career choice and explored their effects in a group of medical students in Singapore. To avoid overloading the regression model, this analysis only included variables shown to have significant association (p<0.05) with the outcome variable from the initial Χ2 test and independent t-test analyses.
Results A considerable number of non-medical school factors such as preschool influence and interest, personality traits and importance of a high status specialty in medicine were found to affect students’ choice of psychiatry as a career. Among medical school factors, attending a psychiatry/mental health club was the only influential factor. Negative attitudes towards psychiatry, but not stigma towards people with mental illness, significantly predicted the likelihood of not choosing psychiatry as a career.
Conclusions Improving educational environment or teaching practice in psychiatric training may aid in future recruitment for psychiatrists. While the changing of premedical school influences or personality factors may be infeasible, medical schools and psychiatry institutes could play a more critical role by enhancing enrichment activities or clerkship experience to bring about a more positive attitudinal change towards psychiatry among students who did consider a career in psychiatry.
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Strengths and limitations of this study
Although studies have examined factors associated with choosing psychiatry as a career, none have looked into such extensive range of factors in a single study.
There have been limited studies that explored psychiatry career among a sample of Asian medical students.
Cross-sectional study design limits the ability to draw causal conclusions.
The lack of qualitative data may also limit our understanding of how students were being influenced by certain factors in determining their career choice.
An estimated 450 million people worldwide are believed to suffer from a mental or behavioural disorder, and one in four people will be affected by these conditions in some point of their life.1 Despite the substantial disease disability and burden associated with mental disorders, there has been a shortage of psychiatrists in the field, sometimes termed as the ‘recruitment crisis’.2 For instance, the number of medical graduates choosing to specialise in psychiatry within the USA has shown a distinct decline from a consistent annual rate of 7%–10% during post-World War II period to approximately just 3%–4% in 2002–2007.3 4 Although recent data from the USA indicates a reversal of trends, WHO data indicates that up to 45% of the world population live in a country that did not meet the recommended ratio of one psychiatrist for every 100 000 people.
Many factors influence medical students’ career specialty decisions, which may be decided before, during or after their training in medical school. The extant literature has emphasised on premedical and intramedical school factors associated with choosing psychiatry as a specialty. The former include gender, ethnicity and exposure to mental illness while the latter include teaching methods, clinical exposure and enrichment activities related to the specialty.5–7 Common reasons for rejection of psychiatry as a career include low respect for psychiatry among the various medical specialties, low salary and negative comments by friends and family about choosing psychiatry.8 9 The attitudes of medical students towards psychiatry have also been one of the most commonly researched topics in the psychiatry career literature. Most studies have reported an overall positive attitude towards psychiatry or a positive attitudinal change following psychiatric clerkship10–12 but despite this, psychiatry as a career choice remains unpopular among students.13 14 Stigma towards mental illness has been increasingly identified as a potential factor that influences medical students’ attitudes towards psychiatry and deters them from choosing psychiatry as a career.15 16 The personality correlates of a career interest in psychiatry were also explored in a few studies.17–19
The recruitment of medical students into the field of psychiatry is important to mental health educators and has also become an increasing priority of healthcare policy makers.20 Given the multifactorial nature of a student’s specialty choice, understanding these factors could aid in the recruitment and mentoring strategies to increase the uptake and quality of students choosing psychiatry.21 The current study, therefore, seeks to identify factors associated with a future choice of specialisation in psychiatry among premedical and intramedical school factors, perception of career aspects, attitudes towards psychiatry, stigma towards mental illness and personality traits in a group of medical students from Singapore.
All students enrolled in two of the medical schools (one undergraduate and one graduate medical school) in Singapore were invited to take part in a web-based survey administered in the English language via school email. The only other undergraduate medical school in Singapore was excluded as it had been recently established at the time of survey administration. A total of 502 students were recruited with quota limits set to ensure adequate and representative sampling of students from each involved institution and across their academic years. Online informed consent was administered prior to the survey.
Patient and public involvement
No patient was involved in this study.
The main online questionnaire in the current study was adapted from a cross-sectional survey that aimed to investigate mostly premedical and intramedical school factors which influence psychiatry as a career choice among medical students across 20 countries.6 We also included additional scales to measure personality and stigma towards mental illnesses. The survey collected sociodemographic data and the following information as described below.
Premedical school factors
These included premedical school influences in choosing medicine and psychiatry (eg, parents’ wishes, wider family and friends’ advices, close contact with a trusted doctor/nurse who is a family member or a close friend, portrayal of doctor/nurses in books, television and the media, personal and family experience of a physical illness or mental illness, prior work experience), premedical school career choice, highest academic qualifications and exposure to subjects prior to admission (refer to online supplementary appendix A for the full list of subjects).
Supplementary file 1
Intramedical school factors
These included intramedical school influences (eg, academics and lectures, school advisors or tutors, clinicians during placement, other students in the same course), psychiatry-related enrichment activities (eg, optional electives, psychiatry/mental health club and programme, research experience, volunteering with mentally ill patients), weeks of psychiatric training attended, clinical exposure factors including reported highest responsibility for patient care during placement and subjects taught at medical schools (refer to online supplementary appendix B).
Importance of career aspects in choice of specialty
These included 12 individual factors namely academic opportunities, research opportunities, competition for training places, flexible working, job prospects, work-life balance, perception of competency, job satisfaction, likelihood of suffering emotional drain/burnout, pay, prestige among general public and high status among medicine. Participants were asked to rate whether each of these factors was important, not important or indifferent in their choice of career.
Two validated instruments—the Attitude to Psychiatry Scale (ATP-18) and the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC)—were also used to measure stigma towards psychiatry and mental illness, respectively. A principal component analysis of the ATP-18 revealed a three-factor structure which reflected 1) an unsympathetic view of psychiatry—its practitioners, patients and treatments, 2) dissatisfaction with the subject matter of psychiatry and 3) approval and interest in psychiatric skills and methods22 while the OMS-HC favoured a three-factor structure, which included 1) attitudes towards people with mental illness, 2) disclosure/help seeking and 3) social distance.23 Finally, for the purpose of measuring the big five factors of personality (extraversion, agreeableness, conscientiousness, neuroticism and openness to experience) in our study, the Mini-International Personality Item Pool (mini-IPIP)24 was included.
Coding of outcome variable
Participants were first asked to rate their likelihood of a career in various specialties—paediatrics, radiography, general practice/primary care, clinical laboratory sciences, anaesthetics, obstetrics and gynaecology, accident and emergency medicine, surgery, psychiatry and general internal medicine—before proceeding to the remaining questionnaire. This variable was measured on a 5-point Likert-type scale (no way, unlikely, possible, seriously considering and definitely). As proposed by Farooq et al,6 the use of this outcome as a continuous variable was not recommended given that it was a subjective ordinal variable and the distribution was also not normal. A preliminary analysis revealed a <10% response rate for students who had endorsed strong likelihood (seriously considering and definitely) for specialising in psychiatry and this would result in a low power for calculation. For the purpose of this study, we have therefore created a binary outcome, with students being ‘unlikely’ to specialise in psychiatry (no way, unlikely) as the interest group versus students being ‘likely’ to specialise in psychiatry (possible, seriously considering and definitely).
Statistical analyses were performed using IBM Statistical Package for the Social Science V.23.0. Statistical significance was set at p<0.05 level. Descriptive statistics were tabulated for the overall sample. Frequency and percentage were calculated for categorical variables, while mean and standard deviation (SD) were calculated for all other continuous variables. Chi-square test and independent t-test were performed to analyse the effects of separate categorical and continuous variables, respectively. A final multiple logistic regression was then performed to examine the factors associated with ‘not choosing’ psychiatry as a career. To avoid overloading the regression model, this analysis only included variables shown to have significant association with the outcome variable from the initial bivariate analyses. A backwards selection procedure was employed to allow elimination of non-significant variables one at a time, based on the probability of the Wald statistic, until only the statistically significant variables remained.
Likelihood of rejecting psychiatry as a career
Only 4 students (0.8%) reported ‘definitely decided to do’, 43 (8.6%) reported ‘seriously considering (ie, top 3 choices), 174 (34.7%) reported ‘possible, unsure yet’, 199 (39.6%) reported ‘unlikely’ and 82 (16.3%) reported ‘no way’ with respect to psychiatry as a career choice. In terms of groupings, the majority (n=281, 56.0%) of the students were ‘unlikely’ (no way, unlikely) to specialise in psychiatry while the rest were in the ‘likely’ group (including those who reported ‘definitely decided to do’, ‘seriously considering’ and ‘possible’).
The sociodemographic characteristics and correlates are presented in table 1. The respondents had a mean age of 22.4 years (SD=3.1, range=16–35) and were mainly females (58.8%), in an undergraduate medical course (76.3%), had a monthly household income of below SGD4000 (37.1%) and were year 1 students (26.3%). Both age and the year of schooling were found to be factors associated with the likelihood of rejecting psychiatry.
Premedical school factors
Table 2 presents the premedical school factors associated with the likelihood of not specialising in psychiatry. Sources of influence that showed significant associations included having close contact with a trusted doctor or nurse, personal or family experience of a physical illness and of a mental illness. The lack of interest in psychiatry and the highest education level attained, both prior to admission, were also significant in predicting the rejection of psychiatry. Our analyses did not reveal significant association with any of the subjects listed in online supplementary appendix A.
Intramedical school factors
Table 3 presents the intramedical school factors associated with the likelihood of not specialising in psychiatry. Sources of influence that showed significant associations included academics or lectures and junior clinicians during placement. Having attended an optional elective in psychiatry and joined a psychiatry/mental health club were associated with choosing psychiatry as a career. Those who completed their clinical placement in psychiatry were less likely to specialise in psychiatry than those who did not. Weeks of psychiatry training received and level of responsibility in patient care were also significant factors for not choosing psychiatry. Our analysis did not reveal significant association with most subjects, except ‘neuroscience,’ taken at medical school.
Career aspects associated with psychiatry as a career choice
Of the 12 individual career aspects, analyses revealed that only those who perceived ‘high status among medicine’ as an important career aspect were more likely to be deterred from choosing psychiatry as a career (table 4).
Attitude towards psychiatry and stigma against mental illness
Table 5 reveals that those who were unlikely to choose psychiatry had significantly lower ATP-18 score (greater negative attitudes towards psychiatry) and higher OMS-HC score (greater stigma towards people with mental illness) than their counterparts.
Among the self-rated personality traits, only agreeableness and neuroticism were found to be significant factors associated with choosing psychiatry as a career on the mini-IPIP. Those who were unlikely to choose psychiatry scored significantly lower in these two personality traits (table 6).
Logistic regression was used to examine the effect of various factors on likelihood of rejecting a career in psychiatry and nine factors remained significant (table 7). Medical students who were unlikely to choose psychiatry as a career were significantly older (OR=1.18), had longer weeks of psychiatric training (OR=2.67 for those with <5 weeks and OR=2.60 for those with >5 weeks compared with those who did not receive any training), and were those who perceived a specialty which has ‘high status in medicine’ as important (OR=1.97), compared with those who were indifferent. Those who had close contact with a trusted doctor/nurse (OR=0.52), interest in psychiatry prior to admission (OR=0.05), postgraduate degree (OR=0.05; compared with pretertiary education) prior to admission, joined a psychiatry or mental health club (OR=0.24) were less likely to reject psychiatry as a career. Lastly, those who were unlikely to choose psychiatry had significantly lower ATP-18 and neuroticism trait scores compared with their counterparts.
The current study attempts to examine the multiple factors identified from the literature that affect psychiatry as a career choice. These factors include premedical and intramedical school influences, career aspects, attitude to psychiatry, stigma towards mental illness and personality traits. While numerous studies have explored factors associated with choosing psychiatry as a career, none have looked into such an extensive range of factors in a single study. A combination of student characteristics, values, needs, medical school experiences and perception of specialties were found to influence the students’ career decision in psychiatry in our sample.
Premedical and intramedical school factors
Both premedical and intramedical school factors were found to influence students’ choice of psychiatry as a career. Our study did reveal a considerable number of non-medical school factors such as preschool influences, personality trait and importance of a high status specialty in medicine to be significant in affecting psychiatry as a career. Preference of specialty prior to medical school was also a strong predictor (OR=10.8) in the study by Farooq et al,6 where 78% of those who expressed interest in psychiatry when entering medical school remained likely to choose psychiatry during their final year. While we did find highest education attained prior to admission to be a factor, no association was found for students’ qualification before medical school in the study by Farooq et al. Our finding on higher neuroticism among those who were more likely to pursue a career in psychiatry was also supported by other studies that cited neuroticism or the presence of emotional disturbance as the central motivating factor in pursuing psychiatric practice.25 26 The underlying psychological conflict of these individuals who choose to become psychiatrists has been described as ‘often severe but not necessarily of neurotic quality’ and they may be searching for an answer to a strong inner drive that seeks to resolve the experienced conflict.27
Manassis et al 28 had identified the most influential career choice factors by psychiatry residents to be initial interest, clerkship experiences and enrichment activities. Similarly, we found enrichment activities such as joining a mental health/psychiatry club (p=0.005) and attending optional courses/modules/ electives (p=0.05) to be influential factors in our final logistic regression. Again, these were two of the six variables that remained significantly associated with students being likely to pursue psychiatry as a career in the regression model of the study by Farooq et al. Studies have also emphasised developing and improving specific enrichment activities such as electives or university psychiatry societies to further enhance recruitment to psychiatry.29–31 None of the preschool subjects or modules/courses taken at medical school was found to be associated with the decision to choose psychiatry as a career choice, although those who took neuroscience were more likely to not choose psychiatry at univariate analysis. Goldenberg and Krystal found that medical students with an undergraduate neuroscience majors preferred to specialise in neurology (21.5%), neurosurgery (13.1%) or internal medicine (11%) compared with only 2.3% who preferred psychiatry at matriculation.32
With respect to clerkship experience, our study may imply that those who were exposed to a clinical placement were more likely to not choose psychiatry as a career choice, although the result was not significant in the multivariable analysis. A study among local medical students revealed positive attitudinal change but worsening associative stigma towards psychiatry following a clinical rotation and suggested that stigma relating to psychiatry could be the main cause for a lack of consideration of psychiatry as a career.11 One possibility could be that the medical students undergoing clinical rotation in psychiatry in Singapore were generally exposed to sicker and more chronic patients which led them to view psychiatry more negatively. Such negative experiences encountered during clinical exposure during the students’ medical school years could lead them to narrow their medical specialty options. However, further qualitative research may be required to establish the underlying reasons.
Studies have generally found that medical students considering a career in psychiatry tend to be exposed to stigmatising comments by others including family members and friends, or the general public on their career choice and therefore, alienating themselves from psychiatry as a career.9 33 However, our study did not find any significant influences due to parents’ wishes, wider family and friends’ advice, prestige among general public or even other students in the same course. Rather, our data revealed factors such as the influence of junior clinicians (but not senior clinicians) during placements and having close contact with a trusted doctor/nurse who could be a family member or close friend to be significant in influencing a career in psychiatry. This probably suggests that the medical students in our sample may be more influenced potentially by contact with healthcare professionals whom they have a stronger sense of connection as compared to those from their social networks.
Attitudes towards psychiatry and stigma towards mental illness
The ATP-18 explores academic and clinical domains as well as perceptions of psychiatrists and psychiatric patients,22 while the OMS-HC assesses stigma and behavioural discrimination towards people with mental illness among healthcare workers.23 Our study showed that those who were likely to reject psychiatry as a career were those who had lower ATP-18 score and higher OMS-HC score at univariate analyses. Multivariate analysis, however, revealed that only ATP-18 score were significant in predicting the likelihood of not choosing psychiatry as a career. This may suggest that medical students in our sample were more likely to reject psychiatry as a career mainly due to their dissatisfaction with psychiatric practice but not because they had a stigmatising attitude towards patients with mental illness or mental illness itself. Our data on ATP-18 were consistent with past research6 34 showing that those who were likely to specialise in psychiatry had a higher ATP score or a more positive attitude towards psychiatry. While strategies on teaching practices such as the exposure to and taking responsibility for patients who are motivated and recovering, as well as co-taught seminars by both patients and professionals to improve medical students’ attitudes towards psychiatry have been proposed,26 35 studies also found that changes in educational environment may not necessarily lead to significant increase in the number of students wanting to pursue psychiatry.11 36
The current study is cross-sectional, and is therefore unable to establish causal relationship between the various factors and likelihood of rejecting psychiatry as a career. For instance, it may be possible that those who were interested in or had decided on choosing psychiatry as a career had also joined the mental health or psychiatry club in their school due to their interest. The lack of qualitative data may have also limited our understanding of how these students were being influenced by their contact with junior clinicians and trusted doctor/nurse, along with the larger-scale cultural issues that might affect their decision to specialise in psychiatry. We are unable to determine the response rate of the study as we do not know how many students had seen the email invitation but decided not to take part in the study. Furthermore, the current study only looked at medical students’ likelihood of choosing psychiatry as career choice in the future and this may not reflect their actual decisions on graduation. Nonetheless, one study had found the stability of psychiatry specialty choice from matriculation to graduation to be at slightly above 50%, which was greater than for any other specialties.37
In Singapore, a graduating medical student would apply to a residency programme in accordance to his choice of medical specialty although there is a selection process where the candidate would be assessed through various ways for his or her suitability for that specialty. Our study has revealed a low interest among medical students wanting to specialise in psychiatry. However, there is a pool of 8.6% of students who would seriously consider psychiatry as a career and this may be the group that could possibly be targeted at to encourage recruitment into the field. While it may not be feasible to change aspects of premedical school influences, medical schools and psychiatry institutes could play a more critical role by improving clerkship experience or enhancing enrichment activities to bring about a more positive attitudinal change towards psychiatry in this group of students.
Contributors LSES wrote the first draft of the article and conducted statistical analyses. BYC, HLO and ES made substantial contribution to the acquisition of data and provided intellectual input. RM, SV, SAC and MS had contributed to the conception and design and provided intellectual input. All authors have given final approval of the version to be published.
Funding This research is supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (Grant No.: NMRC/CG/004/2013).
Competing interests None declared.
Patient consent Not required.
Ethics approval The study was approved by the ethics committee of the Domain Specific Review Board of the National Healthcare Group, Singapore.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement For access to data, please approach Associate Professor Mythily Subramaniam via email@example.com.