|Year : 2018 | Volume
| Issue : 1 | Page : 30-36
Reasons for pursuing psychiatry as a career: A qualitative study of future psychiatrists from India
Priya Sreedaran, Divya Hegde
Department of Psychiatry, St. John's Medical College Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||26-Jun-2018|
Dr. Priya Sreedaran
St. John's Medical College Hospital, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Despite extensive research on the attitudes of medical students toward psychiatry in India as well as worldwide, the actual reasons due to which medical graduates finally select psychiatry for their future careers is still unclear.
Aims: To explore the lived experiences of postgraduate psychiatry students pertaining to their reasons for choosing psychiatry for future specialization.
Settings: In an Indian medical college general hospital psychiatry setting.
Methods and Materials: A qualitative study using focus group discussions and in-depth interviews with postgraduate psychiatry students.
Statistical Analysis: Content analysis was used to identify direct and latent themes and develop a model.
Results: Major themes underlying the reasons for choosing psychiatry are categorised into candidate related factors, medical college related factors, those related to process of Indian postgraduate medical selection, factors relating to psychiatry as a subject and social factors.
Conclusion: The interaction between potentially interested medical under-graduates, their experiences of psychiatry during medical college along with the current system of postgraduate medical selection plays a major role in medical graduates pursuing psychiatry.
Key Message: In order to improve future psychiatry recruitment rates in India, the quality of undergraduate psychiatry teaching should be improved. Professional psychiatry organizations should systematically engage with interested medical under-graduates and try to participate in the postgraduate selection process.
Keywords: Career, medical education, medical graduates, postgraduate, psychiatry, recruitment
|How to cite this article:|
Sreedaran P, Hegde D. Reasons for pursuing psychiatry as a career: A qualitative study of future psychiatrists from India. Arch Ment Health 2018;19:30-6
|How to cite this URL:|
Sreedaran P, Hegde D. Reasons for pursuing psychiatry as a career: A qualitative study of future psychiatrists from India. Arch Ment Health [serial online] 2018 [cited 2019 Feb 21];19:30-6. Available from: http://www.amhonline.org/text.asp?2018/19/1/30/235317
| Introduction|| |
India is currently facing a huge deficit of psychiatrists as well as other mental health-care workers., The National Mental Health Program has attempted to address this by focusing on capacity building and has recommended increasing the number of postgraduate psychiatry seats. However, this measure might not yield results, if we are unable to recruit adequate number of medical graduates to psychiatry. While research has indicated that medical graduates have negative attitudes toward psychiatry, there is very little information on the actual reasons that compel Indian medical graduates to finally select psychiatry as a career.,,
It is in this background that we decided to explore the reasons for pursuing psychiatry as a career among Indian psychiatry postgraduate students.
| Materials and Methods|| |
The aim of the study was to explore the experiences of postgraduate psychiatry students with respect to their reasons for choosing psychiatry as a career.
We adopted a qualitative design as this permitted us to delve into the various aspects in great detail. We followed the Consolidated Criteria for Reporting Qualitative research 32 checklist and other standard recommendations in designing the study as well as reporting on the findings.,
The study was conducted in a private South Indian medical college with a general hospital psychiatry unit and a postgraduate psychiatry program of more than 10-year duration. All interviews with subjects except for two were performed at the study site by the first author with no other person present other than the interviewer and the subject. Two interviews were conducted through teleconferencing with no other individuals present in the interviewer's room at that time.
Both the authors have a combined postgraduate psychiatry teaching experience of more than 10 years. The study was designed by the first author who also carried out all the subject interviews. The first author and the second author jointly did all aspects of the analysis and reporting. The first author was acquainted with all the subjects to some extent before conducting the interviews.
Sampling, inclusion and exclusion criteria
We performed this study on a purposive sample of motivated postgraduate psychiatry students. We deliberately selected subjects who had completed at least a year of psychiatry residency as we assumed that they would have obtained adequate time to reflect upon their choice and would have adapted to their work. We excluded those who had significant absenteeism in their work as this could potentially be a proxy for disinterest in the subject.
We were aware that all potential participants in this study were also simultaneously being supervised by the authors of this study and thus could find it difficult to refuse consent to the study. The study authors had no administrative or disciplinary power over the subjects at the time of conduct of study, and this was clearly stipulated to the subjects at the time of interview. We included transcripts of only those who gave subject informed consent at the time of interview as well as after scrutiny of their transcripts. The study was approved by the Institutional Ethics committee in the year July 2014 (105/2014).
The subject interviews were in the form of in-depth interviews and focus group discussions. On two separate occasions, the subjects were also interviewed in a group of two (dyadic interview) and three (triadic interview). While most qualitative studies use focus groups and single subject in-depth interviews, research indicates that interviewing subjects in pairs or triads is a valid strategy. Whenever more than one subject was being interviewed, the grouping was kept as homogenous as possible so that the subjects would be able to verbalize their experiences freely. The process of conducting the study along with various stages of analysis has been depicted in [Figure 1].
We used a semi-structured interview guide designed on the basis of prior literature review and our findings from a pilot interview. The probes underlying the interview guide were as follows:
- What are the reasons for choosing psychiatry?
- At what time period of their life did they consider selecting psychiatry?
- What were the then underlying influences?
- What was the role of their undergraduate medical education on the choice of psychiatry?
- What were the other factors that contributed to selection of psychiatry?
Altogether we conducted one focus group discussion (n = 6), one dyadic interview (n = 2), one triadic interview (n = 3), and seven single subject interviews. The mean duration of all interviews was approximately 30 min. We directly approached 21 subjects at the study site after observing their work. Three candidates were not interviewed on account of logistic reasons. We obtained 18 interviews. We did not obtain consent from one subject to use the transcript. As we achieved theoretical saturation after the analysis of transcripts of 17 subjects, we stopped recruiting subjects subsequently.
The data were analyzed using the framework of content analysis jointly by the authors who performed a manifest as well as latent content analysis. In the manifest content analysis, the directly expressed words or phrases in the text of the transcript were used to identify important units of meaning and coded in vivo. In the latent content analysis, the aim was to also find out the underlying meaning of the text. We also attempted to generate an overall impression from the text. We used the QSR NVivo 7 qualitative software to perform the manifest content analysis.
We performed the analysis intending to reduce the number of categories and subcategories into broader categories by constant comparison and refinement. We performed participant checking and mailed these findings to the participants with certain other queries to resolve doubts about categories. We incorporated the clarifications from the subjects in the analysis and thus triangulated our data.
We established a set of main categories by grouping together all the subcategories with similar meanings. These were reviewed to identify the emerging themes and categories and were compared to those from previously published literature. Illustrative quotations for most of the subcategories were chosen from the transcripts for the themes according to standard practices in qualitative research., Confidentiality was ensured by removing all identifiers of participants. Each participant instead received an alphanumeric prefix.
| Results|| |
For participant-related details, refer to [Figure 2] and [Table 1].
|Table 1: Participant distribution according to year of residency and gender|
Click here to view
The ages of all the candidates in the study were within the range of 25–35 years. Of the 17 interviewed subjects, one participant considered psychiatry as a future vocation during school, 12 considered psychiatry during medical college and internship, and remaining 4 considered psychiatry while studying for their postgraduate medical entrance examination. While 14 reported that their undergraduate medical education served as a significant influence on their selection of psychiatry as a career, medical college did not play a significant role for remaining three candidates. Ten of the subjects were from a South Indian private medical college with general hospital psychiatry unit, six were from a tertiary central government mental health institution, and one was from a central government training institute with general hospital psychiatry unit.
On analysis of transcripts, the categories were candidate-related, medical college and undergraduate training related, related to process of postgraduate selection, social factors related, and factors related to psychiatry as a subject. [Figure 3] and [Table 2] display all major themes and minor themes with some associated illustrative statements.
|Table 2: Major and Minor themes underlying reasons for selecting psychiatry and illustrative quotes|
Click here to view
Major theme 1: Candidate-related reasons
These were factors that appeared independent of the quality of medical education received by the participants. Some of these factors were inherent in the candidates even before their entry into medicine. Certain other factors appeared to play a greater role toward the end of medical college as the candidates actively began planning for their future.
Major theme 2: Subject-related reasons
This refers to reasons associated with psychiatry as a subject which made it attractive to candidates for their future career. These ranged from the focus on observing and understanding human behavior to the perception of candidates that lifestyle of psychiatrists was less stressful.
Major theme 3: Reasons related to medical college training and education
This appears to be determined primarily by the type of medical education that candidates received. For some candidates, psychiatrists served as inspirational role models.
Major theme 4: Reasons related to process of postgraduate selection in our country
This theme refers to the factors arising from the system of postgraduate selection in India which appears to play an important role in candidates opting for psychiatry. These include a candidate's rank in the examination and candidates' preference for particular national institutes as opposed to a specific medical specialization.
Major theme 5: Social
This referred to the social factors that appeared to serve as motivators for candidates to choose psychiatry. While some candidates selected psychiatry in order to improve stigma associated with mental illnesses, certain other candidates selected psychiatry under the influence of books.
We have further reflected on these themes and have attempted to represent the relationship between these categories using a model [Figure 4].
|Figure 4: Hypothetical model showing the interaction between various themes|
Click here to view
From this model, we hypothesize that candidate-related factors at several stages of the candidate's life along with social factors create an initial tendency toward psychiatry. This interaction under the influence of the quality of exposure to psychiatry received at medical college at undergraduate level further strengthens the inclination toward psychiatry in certain candidates. Some of these candidates due to the postgraduate selection process eventually select psychiatry as a career.
| Discussion|| |
Published literature reveals that, worldwide, recruitment rates of psychiatrists are quite low. In the United Kingdom, the recruitment rates into psychiatry are around 4%–5% with similar depressing figures from other countries.,,, Several authors have tried to understand this by conducting studies on medical graduates using postal surveys, questionnaires, and interview schedules.,,,,, We decided to study postgraduate psychiatry residents as these were individuals who had made a commitment to pursue a future career in psychiatry and were likely to remember the reasons for doing so. Due to the lack of data available from India in this aspect, we used a qualitative design to achieve a deeper understanding of the underlying causes that made certain Indian medical graduates pick a relatively unpopular specialty like psychiatry. Our study demonstrates that there were five major categories that could possibly explain these reasons. While some of these are similar to previously published findings from other countries, certain other factors such as those relating to process of postgraduate medical selection appear unique to our sample.
A theme that came up in our study was that some candidates were inclined toward psychiatry due to their personal experience of a significant loved one being affected with mental illness. This is similar to findings from a large twenty-country study of medical graduates that included subjects from India. Other studies have reported that medical students hailing from liberal arts background were associated with a possible inclination toward psychiatry., We did not come across this in our study. The perceived liberal bias in most potential psychiatrists from the West might not apply to India as most students enter medicine directly after their high school examinations and often have no exposure to the field of humanities after their 10th standard.
In another Indian study that looked at attitudes of medical students toward psychiatry, female medical students were more likely to consider a future vocation in psychiatry. We speculate that women medical graduates, in general, might feel more compelled to take up subjects like psychiatry that are perceived as less stressful for specialization as they might also have to consider the traditional duties expected of Indian women in addition to the demands of a doctor's career. This could be a reason that our study did not uncover a gender-related theme.
Our study demonstrated that psychiatry as a subject was attractive to certain candidates who were interested in studying neurological basis of behavior. These findings are similar to a study done in United Kingdom on consultant psychiatrists where the similarities between psychiatry and neurosciences were among the important reasons for choosing psychiatry as a vocation. Psychiatry was also selected for a future career in view of perceived less stressful lifestyle reflecting upon the increasing current emphasis on maintaining a positive work-life balance.
Our study shows that positive medical college exposure to psychiatry at an undergraduate level including charismatic psychiatry teachers does have the potential to increase the likelihood for medical students to select psychiatry. This is important as many medical students harbor primarily negative attitudes toward psychiatry., Medical students even without any prior clinical exposure have been shown to begin their medical education viewing a career in psychiatry as distinctly less attractive than other medical specialties! A high proportion of medical students from India experienced negative emotions while interacting with mentally ill patients. Medical students, in addition to possessing poor knowledge in the subject, were often unable to conceptualize psychiatric conditions within a biopsychosocial framework and some even believed that supernatural and paranormal reasons caused mental disorders., All of these are indications that, irrespective of whether medical graduates choose to further specialize in psychiatry or not, a lot of effort still needs to be put to remove the various misconceptions against psychiatry as a subject. As several authors have suggested, a greater prominence given to psychiatry in undergraduate curriculum might remedy some of these knowledge gaps.
Social factors such as alleviating stigma associated with mental illness seem to be important reasons for some individuals to choose psychiatry. These bear resemblance to a study in Canada which demonstrated that those students who were more interested in psychiatry had a greater social and lesser hospital orientation as compared to those students interested in other specialties. Popular influences such as books and movies continue to play a role in increasing interest in psychiatry. It is hence necessary that psychiatrists remain sensitive to their popular portrayals and continue to engage with the media innovatively.
Finally, in India, the entire process of postgraduate medical selection brings its own set of variables which have a definite influence on the recruitment rates into psychiatry. With the uncertainty over status of a common entrance examination for medical postgraduation, there is an uneven system of postgraduate admission in India. Our study reveals that some candidates have selected psychiatry on the basis of the institution that they got into and on the basis of their qualifying examination rank. Farooq et al. recommend that countries with low recruitment rates should identify underlying specific national factors. We suggest that various Indian psychiatric associations should take an active role in the entire system of postgraduate medical selection as this is an important variable influencing recruitment into psychiatry.
Another variable relating to process of postgraduate medical selection is the preference of some candidates for central institutes. The government of India's decision to open several central medical institutes might improve future recruitment rates in psychiatry.
We used a qualitative design, and hence our study might suffer from the perceived limitations associated with qualitative research techniques such as small sample size and authors' bias. It is to be noted that, in qualitative studies, theoretical saturation determines the sample size and can be achieved with sample size much lower than that for quantitative studies. The settings from where the subjects were recruited could also have influenced the results. Those subjects from other private colleges or state government psychiatry training institutes might have a different perspective on their reasons for selecting psychiatry. It is also important to keep in mind that there was a prior relationship between authors and subjects, and it is possible that certain subjects might not have fully disclosed their experiences.
| Conclusion|| |
Our study reveals that, in addition to continuing to develop innovative ways to train medical undergraduates in psychiatry, it is important to identify and engage with future psychiatrists at undergraduate level itself. Simultaneously, we should keep in the mind that the current medical postgraduate selection process plays a key role in recruitment to psychiatry and this could influence the future psychiatry recruitment rates as well as the consequent capacity building of mental health services in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thirunavukarasu M, Thirunavukarasu P. Training and national deficit of psychiatrists in India – A critical analysis. Indian J Psychiatry 2010;52:S83-8.
Patel V. The future of psychiatry in low- and middle-income countries. Psychol Med 2009;39:1759-62.
Sinha SK, Kaur J. National mental health programme: Manpower development scheme of eleventh five-year plan. Indian J Psychiatry 2011;53:261-5.
] [Full text]
Praharaj SK, Behere RV, Deora S, Sharma PS. Psychiatric specialization as an option for medical students in the Indian context. Int Rev Psychiatry 2013;25:419-24.
Kato TA, Balhara YP, Chawla JM, Tateno M, Kanba S. Undergraduate medical students' attitudes towards psychiatry: An international cross-sectional survey between India and Japan. Int Rev Psychiatry 2013;25:378-84.
Gulati P, Das S, Chavan BS. Impact of psychiatry training on attitude of medical students toward mental illness and psychiatry. Indian J Psychiatry 2014;56:271-7.
] [Full text]
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.
O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med 2014;89:1245-51.
Morgan DL, Ataie J, Carder P, Hoffman K. Introducing dyadic interviews as a method for collecting qualitative data. Qual Health Res 2013;23:1276-84.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105-12.
Goldacre MJ, Fazel S, Smith F, Lambert T. Choice and rejection of psychiatry as a career: Surveys of UK medical graduates from 1974 to 2009. Br J Psychiatry 2013;202:228-34.
Feifel D, Moutier CY, Swerdlow NR. Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry 1999;156:1397-402.
Wiesenfeld L, Abbey S, Takahashi SG, Abrahams C. Choosing psychiatry as a career: Motivators and deterrents at a critical decision-making juncture. Can J Psychiatry 2014;59:450-4.
Nortje G, Seedat S. Recruiting medical students into psychiatry in lower income countries. Int Rev Psychiatry 2013;25:385-98.
Farooq K, Lydall GJ, Malik A, Ndetei DM; ISOSCCIP Group, Bhugra D. Why medical students choose psychiatry – A 20 country cross-sectional survey. BMC Med Educ 2014;14:12.
Gowans MC, Glazier L, Wright BJ, Brenneis FR, Scott IM. Choosing a career in psychiatry: Factors associated with a career interest in psychiatry among Canadian students on entry to medical school. Can J Psychiatry 2009;54:557-64.
Farooq K, Lydall GJ, Bhugra D. What attracts medical students towards psychiatry? A review of factors before and during medical school. Int Rev Psychiatry 2013;25:371-7.
Prathaptharyan TJ, Annatharyan D. Attitudes of tomorrow's doctors' towards psychiatry and mental illness. Natl Med J India 2001;14:355-9.
Dein K, Livingston G, Bench C. Why did I become a psychiatrist? Survey of consultant psychiatrists. Psychiatrist 2007;31:227-30.
Rao TS, Indla V. Work, family or personal life: Why not all three? Indian J Psychiatry 2010;52:295.
Lyons Z. Attitudes of medical students toward psychiatry and psychiatry as a career: A systematic review. Acad Psychiatry 2013;37:150-7.
Chawla JM, Balhara YP, Sagar RS. Undergraduate medical students' attitude toward psychiatry: A cross-sectional study. Indian J Psychiatry 2012;54:37-40. [Full text]
Rao TS, Rao KN, Rudrappa DA, Reddy DR. Medical students' attitudes to psychiatry: Interest to specialize in psychiatry. Indian J Psychol Med 1989;12:23-8.
Solanki A, Kashyap S. Medical education in India: Current challenges and the way forward. Med Teach 2014;36:1027-31.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]