This study aimed to identify medical school students’ attitudes toward psychiatry and investigate how psychiatry lectures and clerkships could change students’ attitudes toward psychiatry. Our hope was to gain insights to develop better psychiatry curriculums and nurture good medical students. A comparison of those who applied to study psychiatry and those who did not before and after the completion of the psychiatry curriculum showed that there were no significant differences in terms of sex, family type, and growth environment between the groups. Before the implementation of the curriculum, medical school students’ attitudes toward psychiatry were generally positive. Certain attitudes toward psychiatry became more positive after the psychiatry lectures and clerkships were completed; this finding agrees with those of previous studies [1, 2, 5]. The percentage of agreement with the statement “Among mental health professionals, psychiatrists have the most authority and influence” changed from 80.2% before curriculum completion to 95.35% after the curriculum completion; this was statistically significant. Psychiatrists may serve as leaders in teams consisting of a variety of professionals, including nurses, social workers, and clinical psychologists, where they may provide guidance and supervision for treatment while collaborating with other professionals [18]. During the implementation of the psychiatry curriculum, medical school students’ direct and indirect experiences with the role of psychiatry may have brought about positive changes in their perceptions of psychiatrists’ authority and influence.
A statistically significant positive change was observed for the item “Psychiatrists frequently abuse their legal power to hospitalize patients against their will” after the completion of the psychiatry curriculum. Respondents’ agreement with this item fell. Agreement rates were 29.1% before the implementation of the psychiatry lectures, 12.8% after the psychiatry lectures were completed, and 10.5% after the psychiatry clerkship was completed. Psychiatry is, in fact, the only medical department that can enforce compulsory hospitalization against the will of mentally ill patients [19]. Compulsory hospitalization provides treatment to patients in a safe and appropriate way, but some questions remain regarding its social, ethical, and legal justifications [19]. Thus, it is possible that, thanks to the psychiatry lectures and clerkships, medical school students who previously had negative perspectives on compulsory hospitalization received accurate information about the characteristics of and treatments for mental illness; they may have also learned about the criteria necessary for authorizing compulsory hospitalization, and this new knowledge may have affected the reduction in agreement responses to this question.
A statistically significant positive change was also observed for the item “Many people who could not obtain a residency position in other specialties eventually enter psychiatry.” According to the annual report compiled by the Ministry of Health and Welfare, the average rate of choosing psychiatry as the specialty over the past four years has been over 140%; furthermore, psychiatry is a popular specialty that offers a residency position based on students’ competitive performance [7]. These facts may have affected medical school students’ perception of psychiatry residents. Further, although it was not statistically significant, the increase in the proportion of agreement with the item “During my psychiatry rotation, psychiatry residents were good role models” may have had a positive effect on responses for that question.
Before the implementation of the psychiatry curriculum, the only question that received a higher number of responses in terms of negative attitudes was “I feel uncomfortable with mentally ill patients.” The agreement response for the statement was 55.8%, while the disagreement response was 44.2%. Although no significant changes were observed after completion of the psychiatry curriculum, after completion of the psychiatry clerkship the agreement response rate fell to 43.0% and the disagreement response rate rose to 57.0%. This finding agrees with previous research that showed that medical students’ attitudes toward patients were flexible and that psychiatry clinical clerkships could be an efficient way to inculcate more patient-centered attitudes among students [14]. Medical school students’ adaptive tendencies are related to positive experiences, such as vitality and concentration in academic work, and also to confidence in task performance, actions for performing required tasks, and stress levels [20, 21]. These tendencies may also be related to academic self-efficacy and burnout among medical school students in the psychiatry curriculum, which includes psychiatric ward practice, continuous contact with patients, and large amounts of learning, tasks, and tests [20]. In academic performance, higher academic self-efficiency is associated with higher achievement levels and lower burnout. Therefore, in order to bring about improvements in psychiatry curricula, it is necessary to understand the relationships between medical school students’ adaptive tendencies and their positive attitudinal changes toward psychiatry, observed after they completed the psychiatry clerkship. These relationships should be considered in order to bring about future improvements in psychiatry curriculums.
Negatively significant attitudinal changes were observed in the responses to the item “On average, psychiatrists make as much money as most other doctors.” The agreement response rate before the psychiatry curriculum was completed was 57.0%, and agreement rates before and after the clerkship were 51.2% and 36.0%, respectively. Lee [22] reported that income, work burden, and time management were important for investigating the motivation underlying the specialty choices of 154 Korean medical school students. Woodworth et al. [23] reported that medical school students’ income affected their specialty choice, especially due to their increased debt; furthermore, Niaz et al. [24] reported that lower incomes increased students’ hesitation to choose psychiatry as a specialty in comparison to other specialties. Stoddard et al. [25] reported that income affected doctors’ job satisfaction. Therefore, it can be assumed that the attitudinal changes related to income after completion of clinical clerkships are likely to affect medical school students’ specialty choices.
Before completing the psychiatry curriculum, students who had not made any decision regarding specialty choice formed the highest percentage of the students, and students who wanted to choose psychiatry formed the second highest group; these findings agreed with those of other domestic studies [6]. Among the 10 people who wanted to apply for psychiatry before implementing the curriculum, six still did after completing the curriculum. Goldenberg et al. [5] reported that the field of psychiatry offered the highest potential for career stability and that the percentage of medical school students was 50%. In this study, 60% of students sustained hopes to specialize in the field of psychiatry.
However, unlike other studies where psychiatry application rates increased after the curriculum was completed, the current study showed a decrease in intended application rate after curriculum completion [1, 5]. Goldenberg et al. [5] suggested that the high rate of competition for popular specialties may have the effect of decreasing application rates over time, which is a possible reason for our study’s findings. Further, in the Goldenberg study, 80% of medical school students who applied for the psychiatry specialty after completing the curriculum had applied for other specialties before completing the curriculum [5]. In our study, only 14.3% (1 student) changed their specialty choice from another specialty to psychiatry. Goldenberg reported that students who changed their specialty choice to psychiatry were most concerned about “the balance of work and life” followed by “psychiatry clerkship rated excellent” [5]. In previous studies, controlling daily life events through time-management affected specialty choice [26], but our study did not evaluate work-life balance.
The rating of the psychiatry clerkship was evaluated using the Balon scale (specific medical school factors), and attitudes toward psychiatry and the psychiatry curriculum were found to be positive overall. Among these questions, the item “Although I am interested in psychiatry, no effort was made to encourage my becoming a psychiatrist at my medical school” received more than 30% agreement responses and a relatively higher proportion of negative perceptions compared to other questions. However, this study did not assess this issue in further depth.
In this study, we identified medical school students’ attitudes toward psychiatry, attitudinal changes after completing the psychiatry curriculum, and specialty choice-related changes before and after completing the curriculum. Our study can help provide better education for medical school students and foster better psychiatrists. Other studies have had similar goals; Yadav et al. [27] suggested that appropriate modifications to the curriculum could help medical school students improve their attitudes toward psychiatry. Chandrasekaran et al. [28] suggested that modifying the curriculum by focusing on a specific attitude could prove helpful for changing students’ attitudes, since it is impossible to change students’ attitudes totally through just the curriculum. Seong et al. [15] proposed to modify the curriculum based on medical school students’ attitudes, especially in relation to those who experienced negative attitudinal changes after completing the clinical clerkship. By identifying medical school students’ biases and stigmas regarding psychiatry, as indicated in our study’s results, and by reviewing the current curriculum and its effects on attitudes, we can correct and supplement the curriculum as required.
Previous studies have shown that some people do hold concerns and negative perceptions regarding psychiatric treatment [29, 30] and that mentally ill patients often receive other treatment before they begin psychiatric treatment. Thus, other specialty doctors’ attitudes and perceptions toward psychiatry and psychiatric patients could affect early diagnosis and proper treatment for psychiatric patients [16]. Therefore, it is essential to provide medical school students who wish to choose some other specialty with the right awareness and attitudes regarding psychiatry by improving the psychiatry curriculum; this can be accomplished by identifying attitudinal changes after completion of the curriculum and classifying them according to the students’ specialty choices. In this way, an appropriate psychiatry curriculum can improve the early diagnosis and treatment of psychiatric patients as well as cooperation with psychiatrists.
This is the first South Korean study to evaluate medical school students’ attitudes toward psychiatry. Unlike other studies, which only evaluated changes in attitudes before and after completion of psychiatry clerkship, this study provides one major advantage—the comparative analysis of attitudinal changes both before and after a series of curriculum (psychiatry lectures and clerkship) implementations. Furthermore, this study provides another improvement in that the same students were examined (with regard to their attitudinal changes toward psychiatry) as their grades changed.
This study had some limitations, however. First, it is possible that the ceiling effect affected the analysis results. This study categorized survey responses into two types in order to easily identify whether attitudinal changes were positive or negative and to determine how attitudes changed before and after completion of the curriculum. This ceiling effect could be reduced in later studies by assessing students’ responses through subdivision. Second, since questions, which are related to the factors of a specific medical school in the Balon scale, can be answered only after completion of the curriculum, the values measured after the completion of the psychiatry lectures and those measured after the clerkship were compared and analyzed. Therefore, medical school students’ attitudinal changes could not be evaluated in relation to the questions before and after completion of only the psychiatry lectures. If the questions to evaluate the effects of psychiatry lectures on the medical students’ attitude are examined in factors of a specific medical school of a follow-up study, the impact of the psychiatry curriculum on changes in medical students’ attitudes toward psychiatry might be clarified. Last, this study’s results had low generalizability because they were based on data sourced from a single medical school (the medical school curricula across Korea are not standardized). However, it may be more meaningful to understand students’ attitudes and appropriately develop a curriculum based on this study’s results rather than focusing too much on some of the above findings; this approach could enable the provision of a better education for medical students if several medical schools conducted follow-up studies. Such studies should incorporate various evaluation items based on previous studies, such as motivation for admission to medical schools, reasons for choosing a specialty, and grades not included in the current study [9–11].