ORIGINAL RESEARCH PAPER

Year : 2008  |  Volume : 21  |  Issue : 1  |  Page : 117

Withering before the Sowing? A Survey of Oman's 'Tomorrow's Doctors' Interest in Psychiatry

S Al-Adawi¹, ASS Dorvlo¹, C Bhaya¹, RG Martin¹, A Al-Namani¹, A Al-Hussaini¹, A Al-Guenedi^2
1 Sultan Qaboos University, Muscat, Sultanate of Oman
² Department of Behavioral Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Sultanate of Oman, Sultanate of Oman

Correspondence Address:
S Al-Adawi
Sultan Qaboos University, Muscat
Sultanate of Oman

Source of Support: None, Conflict of Interest: None

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2

PMID: 19034834

Objective: This study investigated the attitudes of medical students towards psychiatry, both as a subject in their medical curriculum and as a career choice. Three separate domains were elicited: (i) merit, competency and status; (ii) perceived attitude and attributes toward psychiatry and psychiatric services and (iii) treatment.
Materials and Methods: The 26-item scale Das and Chandrasena Questionnaire was administered prior to and immediately following an 8-week clinical training program.
Results: Results indicate that the perception of psychiatry was positive prior to clerkship and became even more so upon completion of the training. However, there was a significant drop in the proportion of students who indicated that they might choose a career in psychiatry.
Conclusion: This is consistent with other studies suggesting that perception of psychiatry is enhanced following a clerkship but this does not translate into psychiatry as a career intention. This finding is highlighted in light of the increasing magnitude of the number of people affected with mental disorders in a developing country like Oman but with no parallel development in psychiatric services.

Keywords: attitude, perception, psychiatry, medical students, Oman, Arab

Introduction



There is a silent epidemic of psychiatric disorders in many parts of the world, constituting 12% of the “global burden of disease” (World Health Report, 2001). Although a large number of people are likely to become or are already mentally ill, most disheartening is that only a small percentage of newly qualified doctors intend to enter psychiatry (Malhi et al., 2002). Psychiatric services have taken a back seat in health policy planning in most countries, especially in developing countries. In order to spur interest in psychiatry as a career, various studies have attempted to examine the type of medical education that is more conducive to enhancing a positive view of psychiatry. Using different educational methods, studies from different parts of the world suggest a wide variability in the impact of medical education on medical students’ attitudes and perceptions of psychiatry. Many studies have pointed out that exposure to psychiatric services is likely to promote a positive attitude towards psychiatry (Araya et al., 1992; Sloan et al., 1996; Garyfallos et al., 1998). Other studies have reported a contrary view (Al-Ansari & Alsadadi, 2002). In addition, some studies have suggested that holding positive views toward psychiatry does not necessarily translate into students wishing to pursue psychiatry as a career (Malhi et al., 2002; Sierles et al., 2003). What may be surprising is that even those students who were enticed by being exposed to psychiatry and who adopted a positive view and aspirations to becoming psychiatrists tended to steer away from psychiatry over time (Baxter et al., 2001). One aim of this paper was to explore the attitudes and career intentions of medical students in the only university teaching hospital in Oman, Sultan Qaboos University Hospital. Despite great strides in developing healthcare infrastructure in Oman, there are very few locally trained mental health professionals. This suggests that psychiatry has not attracted the attention of tomorrow’s medical doctors (Al-Sinawi & Al-Adawi, 2006).



The medical training offered at the College of Medicine and Health Sciences in conjunction with its teaching hospital entails four years of　basic medical science leading to a Bachelor of Medical Sciences. Among varied courses leading to the Bachelor of Medical Sciences, there are nine mandatory credit hours of Behavioral Sciences taken in three semesters. The contents of the Behavioral Science Modules involve sociology and anthropology of medicine, explanatory models of health, communication skills and the doctor-patient relationship as well as student coverage of psychiatric clinical syndromes that is done via a student-centered learning process (Mpofu et al., 1997; Al-Sinawi & Al-Adawi, 2006). The 8-week clerkship for clinical students is their first exposure to psychiatry. This includes supplementary lectures on various aspects of clinical psychiatry and its allied fields in a multidisciplinary clinical team, patient case presentations, case histories and clinical interviews. This study is an attempt to gauge whether psychiatry and its allied disciplines taught at the College of Medicine in Oman make a difference in terms of students’ impressions of the merit of the psychiatric profession, their general attitude towards it, and their impression about treatment modalities. A related question is to examine whether there are differences in perceptions related to gender.



Method



Subjects



Medical students of the College of Medicine and Health Sciences, Sultan Qaboos University, attending their first 8-week rotation in psychiatry were asked to complete questionnaires during two time periods, before and after their rotation during 2002-2004 - pre-exposure and post-exposure periods. Students were explicitly informed that their responses would remain anonymous and their participation would not earn any special attention from their clinical teams. Participants’ verbal consent was obtained and the study was approved by both the 'Ethics Committee for Human and Clinical Research' and the 'Medical Research Committee'. A total of 207 students were eligible for their 8-week rotation.



Assessment measure



The study questionnaire used was the “Attitudes of Medical Students towards Psychiatry Questionnaire,” also known as “Das and Chandrasena Questionnaire (DCQ)” (Das & Chandrasena, 1988), which is a modified form of the questionnaire devised by Nielsen and Eaton (1981). The DCQ consists of 26 items using a 5-point Likert scale and has been shown to elicit attitude towards psychiatry in past studies (Sloan et al., 1996; Strebel et al., 2000). The DCQ has the additional advantage of appropriately discriminating attitudinal shift between two periods (Das & Chandrasena, 1988). Using open-ended questions, the DCQ provides additional data otherwise unobtainable with a typical Likert scale structured assessment measure (Lopez et al., 2005).



The instrument was administered to medical students in its original English language version as English is the medium for teaching at the Sultan Qaboos University. For present purposes, the items in the questionnaire were operationalized into three interrelated domains as shown in Table 1.



Analysis



Data were analyzed using the Statistical Package for the Social Sciences (SPSS). For the purpose of analysis, individual items were collapsed into three categorical values: agree encompassed ‘strongly agree’ and ‘agree;’ ’neutral’ remained unchanged; disagree consisted of ‘strongly disagree’ and ‘disagree.’ A chi-square test of independence was used to test for association between gender and exposure and the DCQ items. We provide p-values from which Bonferroni’s correction could be applied for the multiple tests. Finally, recurrent themes in the open-ended questions were examined.



Results



Response: A total of 173 students consented to participate in the study. Two students dropped out, leaving a final group of 69 male and 102 female students, for a response rate of 83%. Mean age of the students was 24.5 years with a standard deviation of 1.0.



Merit, competency and status: In general, perceptions toward psychiatry were favorable. Approximately 82% of students disagreed that psychiatry was unscientific and imprecise. The vast majority of students (86%), both before and after their rotation, disagreed that entering psychiatry was a waste of time, and about 61% agreed that psychiatry is a rapidly expanding branch of medicine. However, students were not sure of the monetary rewards of a career in psychiatry; 97 of 166 (53%) were neutral before rotation and 78 of 166 (47%) after rotation. A significantly larger proportion of females, after the rotation, strongly believed that psychiatrists make a lot of money (see Table 1). Before the rotation, 30% of students agreed that psychiatry has a high profile in medicine, with 40% unsure and 30% disagreeing. After the rotation, the number who agreed that psychiatry has a high status significantly increased, while the number of “doubters” decreased. Only 21.6% of students disagreed that psychiatry has a high status within medicine after the rotation. Overall, the positive impressions of the students regarding psychiatry were intact at the end of the rotation.



Table 1:  attitudes of medical students towards psychiatry: pre and post-rotation and differences by gender　







Perceived attitudes and attributes towards psychiatry and psychiatric services: Most students agreed that psychiatrists understand and communicate better with people than the average physician and this number increased after the rotation. However, although a large number of students disagreed that psychiatrists are fuzzy thinkers, a similarly large proportion (42%) were undecided both before and after their rotation. Additionally, a large proportion of the students were undecided about whether or not psychiatrists are apologetic when they teach, and this impression did not change after the rotation. In fact, more students were undecided after the rotation than before, with more female students disagreeing with this statement after the rotation. Further, more females felt that psychiatrists were not apologetic when they taught, and they were more likely to be undecided as to whether non-psychiatric faculty and house staff were critical of psychiatry. Over 57% of students were undecided on this point. An overwhelming number of students disagreed that psychiatric courses were easy. There was also a strong impression that psychiatrists did not abuse their legal powers to hospitalize patients, a view that was reinforced by the rotation. A larger proportion of female students concurred that psychiatrists do not abuse legal powers.



Treatment: More students after the rotation than before recommended psychiatric consultation for emotional problems. Students believed that psychiatrists should have the legal power to treat patients and that it is not the courts, but psychiatrists, who should have the power to decide whether psychotropic medications and electroconvulsive therapy (ECT) should be forced on patients. They disagreed that there is no place for ECT in modern medicine. In this section, for all the nine questions, positive attitudes toward psychiatry were expressed by the students. For six out of the nine questions, there was a significant increase in the already high esteem that the students held for psychiatry.



Career choice: Among the 79 students who indicated their career choice at the beginning of the rotation, 18 (23%) chose psychiatry as a first choice, with 10 % selecting it as second. After the rotation, of the 46 students who declared their specialty intention, only 2 (4.4%) indicated psychiatry as a first or second choice.



In terms of responses to the open-ended questions on the best and worst aspects of their psychiatric posting, 64% of the students indicated the clerkship as “interesting,” 33% as relevant,” while 3% felt that it was “too intense.” Over two-thirds of students felt that the best aspect of the posting was patient-related, that is, they enjoyed dealing with new and different cases, seeing mental illness in “real life” and felt they could also use their social skills. Sixteen percent felt that the best aspect was subject-related, that is, they learned more about human behavior, they studied a new branch of medicine, and they enjoyed the presentations. The remaining 16% of students did not reply.



Sixty-two percent of students cited various problems with the clerkship, including “the posting for 2 months was too long,” “there were very few new patients in the outpatient department,” “strict attendance,” “quite confusing in the beginning,” “boring and repetitive,” “difficult paranoid patients,” and “untreatable disease.” There was no response from 33% of students while 5% did not cite any problems.



Discussion



Attitudes towards psychiatry and mental illness among medical undergraduates are key factors in determining their choice of psychiatry as a career and willingness to deal with psychiatric disorders in clinical practice. In the present study, students indicated positive views towards merit, competency and status of psychiatry at both pre and post-exposure periods, with the positive attitudes further enhanced after the 8-week study period. This was also true with respect to the domain operationalized as perceived attitude and attributes toward psychiatry and psychiatric services, where there were significant improvements in the already high esteem that the students held for psychiatry. These positive attitudes also prevailed for the domain operationalized as psychiatric treatment. Finally, the present data suggest that gender may play some part in the attitude of medical students towards psychiatry, with female students having the most robust positive attitude toward psychiatry.



While the present data indicate a positive perception of psychiatry prior to and upon completion of the psychiatry clerkship there was a significant drop in the proportion of students who indicated they might choose a career in psychiatry. These findings are consistent with reports from other parts of the world that suggest that exposure to psychiatric education tends to result in favorable attitudinal shift by students towards psychiatry (Nielsen & Eaton, 1981; Araya et al., 1992; Sloan et al., 1996; Garyfallos et al., 1998). But, studies have also shown that only a small percentage of newly qualified doctors intend to enter psychiatry (Sierles et al., 2003; Malhi et al., 2002).



Generally, it has been shown that tomorrow’s doctors in developing countries, where 80% of the world population lives, reject psychiatry as a career even if they hold enlightened views towards mental illness (Tharyan et al., 2001; Soufi & Raoof, 1992; Qureshi et al., 1995). Consistent with this, only one student in the present study remained committed to enter psychiatry after the rotation. The lack of career intention toward psychiatry, within the context of increasing mental health problems, has several implications in terms of education and recruitment into psychiatry. This could present a societal dilemma for developing countries since more than 680 million people from these countries have no access to psychiatrists (World Health Report, 2001; Jacob et al., 2007).



While it should be acknowledged that psychiatry is not favorably perceived by medical students from different parts of the world (Soufi & Raoof, 1992; Qureshi et al., 1995; Kuhnigk et al., 2007; Malhi et al., 2002; Sierles et al., 2003; Tan et al., 2005; Tharyan, et al., 2001), it is pertinent to speculate on how Omani culture might have affected the students’ impressions of psychiatry. As in many traditional communities, modern psychiatric care has yet to play a dominant role in the delivery of services for people with psychiatric illnesses. What was deemed as ‘mental illness’ was largely the prerogative of traditional healers. Many people with psychiatric illness are likely to stay ‘underground’ until their illness has reached an advanced stage of irreversible pathology or they go ‘treatment shopping’ as complementary and alternative medicine did not yield the desired results. Traditional value systems in Oman are those that have affinity to collectivistic orientations. In a communal society, from the time of birth, children are brought up in an environment that ushers them into a collective mindset where development of selfhood is generally discouraged, as well as the expression of emotions (Dwairy, 2006). Depending on the level of education, difficulties are attributed to one of four supernatural forces: genie (Jinn or Djinns), contemptuous envy (Hassad), the envy-related ’eye’ (Ain) and sorcery (Sihr). Also, distresses are communicated in "somatopsychic" rather than "psychic” ways.



As traditional Omanis attribute ill-health to external agents, there would be two interrelated implications for psychiatry. When a social impropriety occurs, an individual is likely to attribute his or her difficulty to external forces like Jinn, evil eyes or witchcraft. It is not surprising that many psychiatric problems are first attended to by traditional healers who are sought to exorcise the malevolent spirits. The second implication is that distress in Oman is not perceived as a psychological concept since the collective mindset diminishes the importance of ‘self’ as often expounded in western psychology. As psychiatry attempts to heal the ‘self’, in a society where development of the self is not encouraged, the idea of introspection and intra-psychic conflict and exploration of one’s emotions may be counter to social-cultural teaching (Dwairy, 2006). Although it is possible that medical education that focuses on the biomedical model of disease may have eroded traditional conceptions of self and distress, there is a suggestion that traditional beliefs tend to be deeply imprinted and therefore not easily erased by modern education (El-Islam & Abu-Dagga, 1992). It has been previously shown that medical students in Oman, despite their exposure to biological explanations of disease, still tend to hold the view, for example, that mental illness is caused by sensate agents (Al-Adawi et al., 2002). Within this context, it is possible that cultural patterning may have impacted the perception and attitude towards psychiatry of medical students in Oman.



In addition to cultural patterning, there are also current issues that may play a part in the attitude toward psychiatry. The World Health Organization has recently ranked the healthcare system of Oman as the most “efficient” in the world (Al-Adawi, 2006). Despite this, as elsewhere, mental health services have been inadequately addressed. Most of the services are dispensed in a general tertiary hospital, plus two specialized centers located in the capital. Also, most of the psychiatrists who work in these units are of foreign origin. Above all, the multidisciplinary infrastructures, often essential for psychiatric services, have remained rudimentary due to a lack of suitable manpower. While psychiatric programs are mostly repackaged from Anglo-American models, the community sees little difference between the function of psychiatry and traditional healing (Littlewood & Lipsedge, 1997). In addition, in medical education there is a lack of dialogue between biomedical models that currently appear to focus on neurogenetic determinisms and its upshot, that there is universalism in psychiatric distress (Kiev, 1972) and sociocultural conceptions of mental illness (Kleinman, 1987; Murphy, 1994).



Within these constraints, the challenge in teaching psychiatry and related disciplines is to find teaching materials that are relevant to the situation in Oman. It will therefore be essential to develop curricula that would have a direct bearing on the health needs and beliefs in Oman. By teaching students to reflect on their own culture, it is hoped that this will enhance students’ awareness of the psychosocial realities of their surroundings so they will be better prepared to address these. Bearing in mind that psychiatry focuses on human behavior, integrating sociocultural factors into the education of psychiatry may be paramount, if not essential. This might help to inspire interest in psychiatry for Oman’s doctors of tomorrow.



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