Psychiatry as a Speciality in the Eyes of Future Saudi Doctors: A One year follow up Study

Tabassum Alvi^1*, Aalia A Hayat² and Waqas Sami³

^*Correspondence: Tabassum Alvi, Department of Psychiatry, Riyadh, Kingdom of Saudi Arabia, Email:

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Introduction

Mental disorders constitute a substantial portion of chronic diseases occurring among the general population. Lifetime prevalence in adults is as high as 12.2–48.6 [1]. According to WHO (World Health Organization) survey, suicide will be the leading cause of death by 2020 [2]. However, till 2014, almost 45% of the world's population was living in a country where there was less than one psychiatrist to serve 100 000 people [2], and the highest number of psychiatrists (only 16 per 100,000 population) was in the USA [3]. This increased demand and decreased supply of mental health professionals has led to a huge gap in service delivery for population suffering from mental health issues and situation is understandably worse in the developing countries like Saudi Arabia. There is only 0.4 psychiatrist /100,000 of population in the kingdom [4]. One of the reasons for this dearth is that psychiatric patients and mental illnesses are stigmatized and there is a prejudice and negative attitude towards them in society as well as in the medical community [3].

With already existing gap in service and need, the decreasing trend of medical students to opt psychiatry as a future career is alarming. Need of the hour is to cover this gap by increasing the services available, including mental health professionals in general and psychiatrists in particular. Several studies have been done to assess reasons as to why psychiatry is not one of the prioritized fields of specialization and about ways to increase medical students' interest in this demanding and challenging field. Some studies have shown that a good and structured psychiatry clerkship can have a positive effect on the students regarding their aptitude and may influence their future career choice positively [2]. However, there are others that negate this notion and postulate that such effects are not only minimal but also temporary and fade over time. Viewing the conflicting data regarding training impact on student’s perception and to pursue psychiatry as a career choice, this study was designed to assess any change in student’s views after they got trained through a six weeks of modular system psychiatry clerkship. Secondary objectives were to compare the results of this year's students' attitudes toward psychiatry with that of the previous year in a similarly designed published study while also exploring for any change in the attitude regarding psychiatry as a career choice after a follow up of one year.

Methodology

Study design: It was a quasi- experimental study.

Study subjects: Study participants were 5^th year medical students at the Majmaah University KSA and 6^th year students who were followed up after one year.

Study setting: Majmaah Medical University, Majmaah city, KSA.

Batch of 39 students was recruited in the study through convenience sampling who were about to undergo their six week’s psychiatry module rotation. Updated and modified version of problem based learning psychiatry module was introduced for medical students that comprised of exposure of students to inpatient and outpatient psychiatric clinics. They were involved in assessment and evaluating outcomes of management through case discussions, role plays, debates and a set of formal lectures covering basic areas in psychiatry. Ethical approval was obtained from the Ethical committee of College of Medicine, Majmaah University, before starting the study. Study was designed to get the responses before the commencement of module (pretest) and after the completion of six week’s rotation (posttest) and analyzing any differences in pre and post clerkship responses. The study was explained to the participants and informed consent was obtained. Confidentiality was assured by using anonymous forms. The selfadministered questionnaire used was 30 item Attitude towards psychiatry (ATP-30) scale [5]. ATP-30 measures attitude towards psychiatry using a 5 point Likert scale ranging from strongly agree to strongly disagree. It has questions about attitude towards psychiatry as a discipline, psychiatric patients, psychiatric illness, treatment methods, psychiatrists, psychiatric institutions, psychiatric teaching and psychiatry as a career choice. Half of the statements (15) are positive and half (15) are negative. Positive items are scored from 5–1 whereas negative items are inversely coded. ATP-30 generates a total score ranging from 30–150. The higher the score, the more positive the attitude towards psychiatry. A score of more than 90 would indicate a positive attitude towards psychiatry [5]. In addition to ATP-30 questions, demographic details, along with a few additional questions about quality of teaching and teachers were added to achieve the study objectives. The second set of data comprised of ninety-nine Students of last year batch who completed questionnaire in the previous year post clerkship. Old batch was followed up after one year of attending same module, to observe any change in their attitude about psychiatry as a career choice and otherwise.

Data analysis

The data obtained was subjected to descriptive analysis using SPSS version 23.0. Total score of each student was calculated by adding the score of individual item responses and a mean score and standard deviation along with the frequencies and percentages were calculated for all pre and post-test responses. A comparison was made between the pre and post clerkship mean ATP-30 scores using paired sample t test. Frequencies and percentages of individual items’ responses were calculated after adding up the strongly agree and agree responses as one entity (agree) and adding up strongly disagree and disagree responses as another (disagree) for the ease of analysis. Pre and post responses were then compared using Pearson Chi Square test and Fisher Price test for every item to observe the difference between quantitative variables keeping the p value <0.05. One-way analysis of variance was applied to compare means between more than two group means.

Results

Results from new batch of students 2017

Total participants were 39 out of which 31 appeared for post-test (79.48% response rate). Mean ATP-30 score pretest was 98.35 ± 1.23 as compared to 102.03 ± 2.34 posttest. Though there was an increase in positive attitudes towards psychiatry after rotation, it was not statistically significant (p=0.223). Analysis of individual items showed statistically significant increase in positive attitudes of students towards psychiatry and its teaching (p<0.05) in following domains: "Psychiatrists talk a lot but do very little". Eleven students (33.33%) disagreed before rotation to this negative perception about psychiatrists but it rose to a percentage of 20 (64.5%) (p=0.031).

"Most of the so called facts in psychiatry are just vague Speculations". To this negative attitude towards psychiatry as a scientific subject, initially only 4 (12.8%) students disagreed which rose to a significant 12 (38.7%) with a p value of 0.025 after rotation.

"Psychiatry is so unstructured that it cannot really be taught effectively." Initial response of students to this negative concept about psychiatry yielded a response of disagreement from only 5 (15.4%) students that rose to a huge 18 (58.1%) after the rotation in psychiatry (p=0.01).

Table 1 shows questions other than ATP-30 to assess the views about psychiatry rotation and the psychiatrists as role models (p<0.05). ANOVA showed that higher the score of a student on ATP-30, higher are chances of him choosing psychiatry as a future career (p=0.002).

Table 1: Questions about psychiatry rotation and psychiatrists as role models other than ATP.

Results of follow up of old batch of medical students after one year

Ninety-nine students responded Post-test last year. The same students were followed up this year. Mean ATP score was found to be 113.08 (SD 15.66) last year but on follow up it dropped to 96.50 (SD 17.03). The difference was statistically significant with a p value=0.001 (Tables 2 and 3). In response to the question about taking psychiatry as a future career, number of students who agreed to choose psychiatry as future career rose from 26 (25.9%) to 46 (45.5%). However, the change in response was not statistically significant of the students. Rather, in the question regarding perception about efficacy of psychotherapy, there was a mixed response. Initially most students i.e. 74 (73.3%) had difficulty accepting psychotherapy as being effective. After one year 46 (45.5%) were unsure about its efficacy as a therapy. So more students moved from a negative perception to a not so sure domain which could be considered as positive change. The perception regarding psychiatrists being good role models remained unchanged with time.

Table 2: Questions from ATP-30 showing significant change in responses after one year of follow up.

Table 3: Questions other than ATP-30 showing significant change in responses after one year of follow up.

Discussion

Change in Attitude towards psychiatry

In this research, students developed overall positive attitude towards psychiatry after rotation. Though before the rotation, pre-test score was 98.35 which represent a positive attitude, it further rose to 102.03 post rotation. Similarly, in a systemic review, a mix of positive and negative attitudes toward psychiatry were identified but overall attitudes were found to be positive [6]. This is a very important development as a statistically significant association was found between high ATP-30 score and choice of psychiatry as a career in this study as well as previous studies. [7], This implies that by working on ways to improve student’s attitude, we can increase the likelihood of more future doctors choosing psychiatry as the field of future specialization.

Role of psychiatrists

In a previous study, students’ positive attitude towards psychiatry was found to be directly related to psychiatry course rating and mentoring from charismatic teachers [7,8]. Similarly, our students considered psychiatry teachers as role models and this view rose significantly post clerkship. Another similar study stated that inspiring, motivating and enthusiastic role models influenced on pursuing psychiatry. Some studies however exhibited contradictory findings as well, like one in which Chinese medical students thought that psychiatrists were not as good as the doctors working in other specialties [9].

Psychiatry as a career choice

Most promising finding of our research was that more students considered psychiatry as career choice after the rotation. These findings were similar to the findings of our previous batch study from same college one year ago [3]. On one year follow up of the same batch, the number of medical students who opted psychiatry as a future career not only persisted but rose from 25.9% to 45.5% [3], (overall rise by almost 30% in one year). Similarly, in a systemic review, six studies found incidence of choosing psychiatry as a career to be 10% or more [9]. Another study from Iran interpreted; stigmatization of psychiatry discourages students while clinical placement can improve choice of psychiatry as a future career [10].

Attitude and career choice after one year follow up

Though there was a rise in percentage of students opting for psychiatry as a future career, ATP-30 score before and after one year of psychiatry rotation dropped significantly from 113.08 to 96.50. The areas in which the perceptions got negative seemed to be related to the inherent nature of the psychiatric illnesses: the diseases being chronic and not responding instantly to therapy like rest of the medicine.

The statements yielding more negative responses were for e.g., “Psychiatry is unappealing because it makes so little use of medical training” and “There is very little psychiatrists can do for their patients.” This could be understood in the background that usually psychiatrist emphasize at utilizing psychotherapeutic (non-drug) methods initially or as an essential part of treatment plan which might appear as “non-medical” or “just talking” in the eyes of future doctors. Also there were negative perceptions about psychiatrists talking about nothing but sex. This perception could be explained by the fact that complete wellbeing is related to being physically, psychologically, sexually and spiritually well and psychiatrist try to follow a bio-psycho-social model in assessment and management of their patients. Sexual disorders and difficulties form a major component of psychological and psychiatric disorders that usually gets unnoticed and undiagnosed if not investigated openly. Psychiatrists usually come forward and talk about investigating and managing these disorders which is contrary to the normal cultural practices. Openness of psychiatrists to talk about these tabooed issues might come as a surprise for the under training medical students. Negative perceptions were found about the psychiatric settings and hospitals, which students declared to be a little more than prisons. Though a lot of reorganization and restructuring is going on in Saudi Arabia regarding mental health reforms, yet the facilities are not as equipped and modernized as the other medical or surgical departments [11].

Contrary to these negative findings, on one-year follow up, students retained psychiatry as their career choice which is in accordance with a few previous studies [12]. Other positive findings on follow up were an increase in the notion about psychiatry having scientific information. This might be a reflection of effective incorporation of more scientific evidence in the revised curriculum. Yet another positive change was regarding the notion that psychiatrists make less money than other specialties. This notion decreased from 13.3% to 7.7%. This is a very significant finding as previous studies have identified that medical students were more inclined to see psychiatry as being less financially rewarding and having low social prestige which is indirectly associated with low income [9]. So a decrease in this negative perception might translate into more students choosing psychiatry as their future career.

Limitations

It was a convenience sample so the results are not generalizable to all the medical students in the kingdom. There is variability in syllabus and mode of teaching at different institutions so replicating the study might yield results accordingly.

Conclusion

Although the desire to pursue psychiatry as a career was raised during training and even after one year amongst students, psychiatrist was considered as good role models and time spend in rotation was rated worthwhile by students, a lot remains to be changed. Negative attitude of the students can be altered by giving exposure to ailments that have shorter recovery periods, usage of newer drugs and demonstration of more effective strategies in a systematically organized and conducive environment. Improvement needs to be done in overall structure and facilities provided to the psychiatric patients as up to the mark service and respectable and comfortable settings and are also determinants of career choice along with the right aptitude, scientific teaching and provision of good role models.

Acknowledgment

We would like to Thank Deanship of Scientific Research, Majmaah University for funding this work via a year project number R-1441-8. We would also like to thank Ibrahim B Alhuzaymi, medical student of College of Medicine Majmaah University for providing us support in data collection.

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