Medical Education 1987,21,227-234

Students’ attitudes towards psychiatry

F. CREED & D. GOLDBERG

Department $Psychiatry, University ofh’anchester

Summary. Using a reliable measure, a self- administered questionnaire (ATP), and ade- quate numbers of students, this study demons- trates the negative effects of general medical/ surgical training and the positive effect of the psychiatry clerkship on students’ reported atti- tudes towards psychiatry. A negative view of psychiatry at the beginning of the clerkship may make students reluctant to improve their interview skills but is otherwise unimportant in determining their reactions and performance in the clerkship. Medical students’ interest in psychiatry as a career increases during the psychiatry clerkship but this merely offsets the decline in interest that occurs at other stages during the clinical training.

Much of the attitudinal change that occurs during the psychiatry clerkship is maintained into the pre-registration year but the housemen recorded a significant negative change on the items concerning efficacy of psychiatric treat- ment and attitudes towards psychiatric patients. Additional training by psychiatrists during the pre-registration year might increase the motivation of young doctors to detect and treat psychiatric illness which they will encounter in all branches of medicine.

Key words: *Students, medical; *attitude of health personnel; psychiatry/*educ; *clinical clerkship; career choice; England

Introduction

Attitudes of medical students towards psychia- try have been studied to assess the effect of

Correspondence: Dr F. Creed, Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Manchester M I 3 9WL, England.

psychiatry teaching and also to try and under- stand why recruitment into psychiatry has been poor (Editorial 1973; Editorial 1979; Nielsen & Eaton 1981). Studies of students’ attitudes be- fore and after the psychiatry clerkship have generally produced evidence of a positive change in attitude but they have used different means of measuring attitudes (which have been largely unstandardized) and small numbers of students.

The factors which lead to a positive attitu- dinal change during the clerkship are not well defined, but may be associated with students taking direct patient responsibility (Lau & Offord 1976; Maxmen 1979) and exposure to patients with psychiatric illness which responds rapidly to treatment (Eagle & Marcos 1980). It has been demonstrated that attitudes are unre- lated to students’ performance in an examina- tion at the end of the psychiatry clerkship (Lau & Offord 1976; Larson et a l . 1980; Wilkinson et al. 1983a). With regard to career choice, some measures of attitudes have been strongly corre- lated with career choice (Wilkinson et a l . 1983a), but others have found that a positive attitude towards psychiatry is not necessarily correlated with an intention to pursue it as a career (Lau & Offord 1976; Creed & Goldberg 1987).

Burra et a/. (1982) developed a questionnaire to measure medical students’ attitudes towards psychiatry; this was standardized and validated on a large number of students and found to have a high test-retest reliability. Use of this questionnaire indicated that attitudes towards psychiatry were stable over a period of training unrelated to psychiatry and significantly im- proved during a psychiatry clerkship, although the improvement was shortlived. This is in agreement with Rezler’s finding (1974) that

228 F . Creed G. D . Goldberg

attitude changes induced by participation in special programmes are temporary at best un- less supported and reinforced by the total medical school environment. Other longitudin- al studies have suggested that attitude change which occurs during the psychiatry clerkship is maintained over a period of time (Miller et a l . 1979; Wilkinson et al . 1983b). However, Kausch (1969) found a significant change of attitudes towards psychiatry in a negative direction be- tween commencing the medical course and the time of the psychiatry clerkship. This may be part of a general change in attitudes during medical training, which includes a decreased interest in the psychological aspects of disease between the first and final year (Donnan 1976) and a decline in psychiatry as a career choice between first and final years (Martin & Boddy 1962; Royal Commission on Medical Educa- tion 1968; Donnan 1976). Increased cynicism has been demonstrated during the medical training (Editorial 197s).

This study was designed to assess the change in medical students’ attitudes towards psychia- try during the clerkship; to try and understand what aspects of the clerkship were related to attitudinal change and to put it in the context of attitudinal change at other times during the clinical training and after qualification. The psychiatry training at Manchester has been described in detail elsewhere (Goldberg et a l . 1983) and the clerkship occurs in the second clinical (i.e. fourth) year. There are approx- imately 250 students in each year who take psychiatry in cohorts of about 50. These 50 students are taught as a single group during the introductory week which is followed by clinic- al teaching on one of seven clinical units over the next 8 weeks (i.e. seven students per unit).

Method

All students in one academic year were asked to complete the Attitudes Towards Psychiatry Questionnaire (ATP) (Burra et al . 1982) at the beginning of the psychiatry clerkship (before the first lecture) and at the end of the clerkship. All those who had qualified and who could be traced through the Dean’s office were sent a further ATP 2 years later during their pre- registration house jobs. These students also

completed feedback questionnaires after the introductory week of the clerkship and at the end of the clerkship. It was made clear to the students that their questionnaire scores would be kept confidential and could not therefore influence their teachers or their examination results. However, the results of the examina- tion were made available to the researchers to compare academic performance and attitudes.

For comparison purposes all the students in a separate academic year completed the ATP during the first week of their clinical training (beginning of the third year). All students were asked to indicate their probable career choice and their likelihood of pursuing a career in psychiatry.

The ATP has 30 items which are scored on a 5-point scale of agreement. The items are phrased to include positive and negative state- ments, but they are scored in such a way that a high score indicates a favourable attitude to- wards psychiatry. The maximum score is therefore 150. The results of the ATP are given as a total score, and changes on individual items are also reported; in both cases the Wilcoxon matched pairs sign test was used to assess statistical significance of differences be- tween groups. In order to study the rela- tionship between attitude to psychiatry and the students’ appreciation of the teaching and academic performance, the cohort was divided into quartiles according to their ATP score at the commencement of the clerkship. Compari- son between the third-year students (during their first weeks of clinical training) and the fourth-year students at the beginning of their psychiatry clerkship was made using a 2 test.

Results

A total of 265 students completed the question- naires at the beginning of the psychiatry clerkship (a 100% response rate) and 261 at the end. A total of 226 of these students completed them again during their pre-registration year. O f the remaining 43 students, 17 failed to pass their finals at the first attempt and a further 10

students could not be contacted during the pre-registration year. Thus only 16 housemen who received a questionnaire did not return them. This is a response rate of 93%. A

Students’ attitudes towards psychiatry 229

separate cohort of 247 third-year students com- pleted the questionnaires.

(I) Total ATP score

For the 261 students who completed ques- tionnaires at the beginning and end of the psychiatry clerkship the mean total ATP score changed from 98.1 (k9.7) to 108.1 (k11.3). This is a significant change representing a more positive attitude towards psychiatry (P<o.oooI). However, the initial score was similar to the mean total ATP score obtained from the 247 third-year students (98.4sk11.3).

For the cohort of students who completed all items of the questionnaire on three occasions before and after the psychiatry clerkship and as housemen, the total ATP scores were 98.47 at the beginning of the clerkship, 1091 at the end of the clerkship and 106.7 as housemen. The differences between the first two scores repre- sent a significant improvement in attitude to- wards psychiatry during the psychiatry clerkship (P<o.ooos) and a smaller, but still significant, change in an unfavourable direction between the end of the clerkship and the pre-registration year (P=o.022).

The overall ATP score change conceals the fact that a minority of students (14%) have a lower score at the end of the clerkship, indicat- ing a less favourable attitude towards psychia- try. There is a general trend for those with low initial ATP scores to show a greater increase in their scores after the clerkship compared to those with high initial scores (Table I). Stu- dents are clearly quite flexible in their attitudes at this time.

( 2 ) Individual items of the ATP questionnaire

As well as the total ATP score the individual items on the questionnaire were examined to see whether particular aspects of attitudes changed in the same way. The first comparison records any change of attitude that occurs during approximately I 8 months of training in medicine, surgery and paediatrics. Compared to the scores of the third-year students, the fourth-year students at the beginning of the psychiatry clerkship showed a significantly more favourable attitude on seven items (these items concerned the teaching of psychiatry and psychiatric hospitals as institutions). They showed a significantly less favourable response

Table I . Change of ATP between start and end of clerkship by auartiles (median and range)

Quartile Before clerkship After clerkship

( I ) With lowest initial

( 2 ) With low initial

(3) With high initial

(4) With highest initial

ATP score (n=65) 87.8 (6c-92) 101.9 (71-130)

ATP score (n=67) 96.3 (93-98) 105.2 (58-132)

ATP score (n=60) 101 ( 9 F I 0 3 ) I 12.7 (83-128)

ATP score (n=73) 107.6 (104-126) 113.9 (89-138)

Table 2. Interest in a career in Dsvchiatrv

Fourth-year clerkship

Third year Before After Items (n’247) (n=265) (n=261)

( I ) Definitely averse I I % 14% 9 % ( 2 ) Don’t on whole want 3 9 % 47% 42% (3) Would consider 3 8 % 32% 3 2 % (4) Would seriously consider 12% 7 Yo 16% ( 5 ) Definitely committed I %

Pre- registration

year (n=zzz)

20%

24.5% 10%

0.5%

45%

230 F . Creed G D. Goldberg

on six items concerned with the efficacy of psychiatric treatment, the image of psychia- trists and the intention to do psychiatry as a career.

Between the beginning and end of the psychiatry clerkship a significantly more favourable attitude was recorded on 2 1 of the 3 0 items. All the items on the questionnaire regarding psychiatrists, psychiatry as a career choice and psychiatric hospitals showed a signi- ficantly more favourable response at the end of the clerkship. The majority of items concerning teaching, treatment and nature of patients seen in psychiatry showed a similarly significant change, but the majority of items concerning the scientific status of knowledge in psychiatry did not show a significant change after the clerkship. The only item to show a (non- significant) change in a negative direction was the item ‘psychiatry is a respected branch of medicine’.

Compared to their scores at the end of the psychiatry clerkship, the pre-registration housemen (n=zzz) showed a significantly more favourable attitude on two items of the ques- tionnaire, but a significantly less favourable attitude on 10 items. These were: efficacy of psychiatric treatment (four items), importance of psychiatric teaching (two items), psychiatry as a career choice (two items) and work with psychiatric patients (two items). For the items concerning career choice and work with psychiatric patients the scores dropped to those recorded before the psychiatry clerkship, but for the other six items (treatment and teaching) the scores reflected attitudes that remained more favourable than those expressed at the beginning of the clerkship.

(3) Caveer choice

The results regarding career choice must be considered in the light of the students’ lack of definite choice at this stage. Only I % of third-year students, 7% of fourth-year students and 27% of pre-registration housemen were definite about their stated career choice. But the proportions choosing each specialty were almost identical in the fourth year and as housemen (general practice 38%, medical spe-

cialties 3 I % , surgery zo%, paediatrics 8%, psychiatry 2% and non-clinical I%) .

The results regarding a career choice in psychiatry are shown in Table 2. The propor- tion of students who would consider a career in psychiatry is less at the beginning of the psychiatry clerkship (39%) than at the begin- ning of the third year (50%) @=6.629, P<o.oz). The proportion rises to 49% at the end of the clerkship but falls to 35% during the pre-registration year p= 10.12. P<O.OI). In response to a direct question regarding the effect of the clerkship, 11% of students stated that they were less likely to choose a career in psychiatry, 23% were unchanged in their views, 55% were somewhat more likely and 11% were much more likely to choose psychiatry. This change was independent of initial attitude; two-thirds of those with a low initial ATP score were more likely to do psychiatry, which is the same proportion as those with a high initial ATP score.

Considering only the 222 students who com- pleted ATPs during the pre-registration year, 40 of those who would consider a career in psychiatry at the end of the clerkship would n o longer consider doing so when asked as house- men, whereas 1 3 doctors changed their view in the opposite direction. This is a significant negative change (McNemar test for change

There is, not surprisingly, a strong correla- tion (P<o.ooI) between total ATP score and interest in psychiatry as a career (four of the 3 0 items on the ATP questionnaire are specifically related to psychiatry as a career). At the begin- ning and end of the clerkship the total ATP scores are practically identical when the stu- dents are grouped according to first choice of specialty (medical, surgical, general practice, psychiatry and non-clinical). At the houseman stage, the scores are more scattered (paediatrics and surgery 104, medicine 106, general practice 108 and psychiatry I 16) but these differences are not significant except for those who listed psychiatry as a first choice of career (five students at the beginning of this clerkship and six pre-registration housemen, P<o.ooI).

Although there is an overall correlation be- tween students’ general attitude towards psychiatry and their interest in psychiatry as a

P<O.OOI).

Students’ attitudes towards psychiatry 23 1

career, nearly half of those who commence psychiatry with the most positive attitude to- wards psychiatry (top quartile) do not wish to pursue a career in psychiatry. A total of 14% of those who hold the least sympathetic attitudes initially (bottom quartile) would seriously con- sider a career in psychiatry at the end of the clerkship. Students are clearly far from fixed in their career choice at this stage.

For each student the change of interest in psychiatry as a career before and after the clerkship was calculated using the 5-point scale of Table 2. This change of career choice was significantly correlated with the change of ATP score (Spearman correlation coeficient=o.js, P<O.OOI) and two parameters of clinical experience (see below).

(4) ATP score, appreciation of teaching and ex- amination performance

Initial ATP score, i.e. attitude towards psychiatry at the beginning of the psychiatry clerkship, was not related to the students’ later evaluation of the teaching they received. At the end of the introductory course attitude was not related to whether theoretical lectures or videotaped instructions on interview skills were preferred, but those with more sympathetic attitudes were more ready to clerk their first psychiatric patients (P<o.os). At the end of the clerkship, students’ performance in videotaped, multiple choice question (MCQ) and clinical examinations were not related to their initial attitude. The students’ assessments of the diffe- rent forms of teaching (lectures, seminars, textbooks, videotapes, ward round, out-patient and direct clinical work with patients), their preferences for lecture topics, and the number of patients they had clerked were all unrelated to the initial attitude, with the one exception that those with the least sympathetic attitudes were significantly more likely to regard their training with interview skills as poor.

( 5 ) ATP score and clinical experience on different clinical units

The students gained clinical experience dur- ing the psychiatry clerkship on seven different clinical units. Each unit taught between 32 and

40 students during the year of study. The change in ATP scores before and after the clerkship did not differ significantly between the clinical units. However, the number of in-patients and out-patients clerked did vary significantly between the units, and there was a low, but significant, correlation between change of interest in psychiatry as a career and number of patients seen (Spearman correlation coefficient=o. I 5 , P<o.oI).

The change of interest in a career in psychia- try was significantly different between the units (K-W one way analysis of variance, P<o.oz). O n one unit the number of students who would consider a career in psychiatry was slightly reduced at the end of the clerkship, on two units the number changed little and the remaining four units were responsible for prac- tically all the net gain in those students who would consider a career in psychiatry. There was a significant correlation between the units ranked according to the number of patients clerked and the effect of the course on the students’ interest in psychiatry as a career (Kendall’s tau=o.6g, P<o.o~). But the number of patients seen cannot be the only factor determin- ing interest in psychiatry, since the unit on which the students clerked most patients was one on which there was no change in the proportion showing interest in psychiatry as a career.

General comments

When asked to make general comments about the clerkship 47% of students said the teaching was good, 12% commented there were insuffi- cient patients, 1 1 . 5 % commented there was inadequate clinical supervision and the remain- der made a variety of other general comments. These comments were not related to students’ initial attitudes but the complaint of insufficient patients was significantly related to clinical unit

The students were asked to state what they themselves had found the least attractive aspects of psychiatry as well as the reasons why psychiatry was generally regarded as an un- popular specialty. The results appear in Tables 3 and 4. Only one of these items was signifi- cantly related to initial attitude: disagreement

(P<0.02).

232 F . Creed G D . Goldberg

Table 3. Students’ reports of the least attractive aspects of psychiatry

Aspects of psychiatry

No unattractive features Chronic illness unresponsive to treatment Aspects of psychiatric patients and their behaviour Disagreements between psychiatrists regarding classification and theoretical issues Aspects of teaching or the examination Clinical psychiatry affects the students themselves Psychiatric treatment (ECT, compulsory treatment, etc.) Staffs (negative) attitude towards patients Staffs attitude towards students Miscellaneous

Total

n

5 46

Table 4. Students’ opiniom on why psychiatry is an unpopular specialty

Students’ opinions

Unscientific, doesn’t use medical skills and different from rest of medicine Low status within medical profession Undergraduate teaching not so good nationwide as in Manchester Ineffective treatments in psychiatry Stigma of psychiatry among general public Doctors are affected by working with psychiatric patients Psychiatrists as a group of doctors Miscellaneous No reason given

Total

n

74 63 3 1 23

I S 7 7

25

26s

20

between psychiatrists regarding classification and theoretical issues was reported by 15% of those with low initial ATP scores and 4% of those with high scores (P<o.os). This was one of the t w o items that showed a significantly skewed distribution across the clinical units (P<o.oI). The other unattractive feature signifi- cantly related to clinical unit (but not initial attitude) was aggressive or difficult behaviour among psychiatric patients (P<o.os). Whereas the low status of psychiatry within medicine as a whole is quoted most frequently as the reason for poor recruitment (Table 4), for the students themselves it is their perception of chronic and unresponsive illnesses in psychiatry that they find unattractive.

Discussion

Like previous studies (Lau & Offord 1976; Burra et a l . 1982) w e have found a very considerable positive change in students’ atti-

tude during the clerkship. This attitude change involves nearly all aspects of psychiatry with the exception of the scientific status of the subject and its relationship to the rest of medicine. The fact that many students show very considerable changes in ATP scores and interest in psychiatry as a career emphasizes the great flexibility o f attitudes held by the students at this stage of their training.

The students’ initial attitudes towards psychiatry are surprisingly unimportant in de- termining their response to many aspects of the psychiatry clerkship. However, reluctance to clerk the first patient and a negative view of interview skill training are related to a negative initial attitude as measured by the ATP. These are areas where negative attitudes may prevent the acquisition of essential clinical skills and may correspond with the finding of Maguire et a l . (1978) that a few students have persistent difficulties in this area even with specific train- ing.

Students’ attitudes towards psychiatry 233

Increased interest in psychiatry as a career develops during the clerkship independent of initial attitude but is related to the clinical unit and the number of patients seen. Seeing many patients may make the student feel involved in the clinical work of the unit, which has been found to be a positive feature in other studies (Lau & Offord 1976; Maxmen 1979). Alterna- tively, the high throughput of patients on these clinical units may help prevent the students from gaining the impression that psychiatric illnesses are chronic and unresponsive to treat- ment. This impression has previously been quoted as a reason for poor recruitment into psychiatry (Nielsen 1979; Hutt et al . 1981; Creed & Goldberg 1987). Conversely, Eagle & Marcos (1980) suggested that a critical issue affecting students’ attitudinal change was their perception of the treatability of the patients.

However, in the present study, one of the three units which produced greatest positive change in interest in psychiatry as a career was one on which very few patients were seen. Presumably, there are aspects of the teachers and their work which students find appealing. Clarity of teaching is clearly important as those students who reported that confusion or con- tradiction between teaching sources was an unattractive feature did not become more in- terested in psychiatry as a career. Eagle & Marcos (1980) noted that diagnosis and treat- ment within the medical model was rated by medical students as a valuable learning experi- ence.

The present study has examined attitudinal changes outside the psychiatry clerkship as these may be relevant to recruitment (Russell 1979) and any change occurring during the clerkship should be viewed against this back- ground. It is a shortcoming of the present study that a different cohort of students was studied in the third and fourth years. However, with such large numbers it is difficult to argue that the differences in ATP score between the onset of clinical training and the middle of the fourth year are the result of collecting data from different samples.

During the third year, when students are exposed to general medical and surgical teaching, the overall ATP score changes little. During this time the students seem to feel

increasingly positive about the importance of teaching in psychiatry but adopt a more nega- tive view of the efficacy of treatment in psychiatry and of the image of psychiatrists. These changes are accompanied by a consider- able drop in the proportion who would consid- er a career in psychiatry. Similar changes occur between the end of the psychiatry clerkship and the pre-registration year. Since it has been shown that students adopt the attitudes of their clinical teachers (Harris I974), this is presum- ably the origin of these attitudinal changes. It has been shown that students view psychiatrists according to a stereotype which changes in a negative direction during the medical training (Harris 1981). Similarly, the view that psychiatry is not a respected branch of medi- cine is gained during general medical and surgical teaching and is unaffected by the otherwise favourable experience of the psychiatry clerkship.

There is evidence in the present study that some of the positive changes in attitudes that occur during the psychiatry clerkship remain into postgraduate training as previously reported by Miller et al . (1979) and Wilkinson et al . (1983b). ButlikeBurraetal. (1982) wefoundthat all the positive changes are not maintained and it is likely that some of the attitudinal change reported at the end of the psychiatry clerkship is temporary because it is not ‘supported and reinforced by the total medical school environ- ment’ (Rezler 1974).

The proportion of pre-registration doctors in the present study who would consider a career in psychiatry (35%) is not dissimilar to that reported in 1963 in final-year students (42%) (Walton et al . 1963). The great improvements in psychiatry teaching that have occurred dur- ing the intervening decades seem to have made little impact on the prevailing attitudes towards psychiatry in medical schools. This study, together with a parallel study of pre- registration housemen (Creed & Goldberg 1987), indicate the need for greater involve- ment by psychiatrists in the pre-registration year. Doctors at this stage need to be super- vised in their use of psychological methods of treatment so they can appreciate the efficacy of such treatments and offer appropriate care to their patients thereafter.

234 F . Creed G.

Acknowledgement

This study was carried out with the help of a research grant from the Mental Health Founda- tion.

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Received 12 June 1986; editorial comments to authors 13 November 1986; accepted for publication 23 January 1987