Impact of duration of psychiatry rotation on medical interns ’ attitude towards psychiatry

Background: Medical Council of India allowed the interns to take up an extra 15 days of elective posting in psychiatry along with the mandatory posting of 15 days. The study was planned to assess the effect of the additional period of psychiatry internship on the attitude of interns towards psychiatry. Material and methods: The consenting interns were given a semi structured proforma enquiring about their age and gender and were asked to fi ll up Attitude Towards Psychiatry (ATP) scale. The assessment was done at the beginning and then after 15 days of mandatory posting. Those participants who were willing to do an additional 15 days of elective posting in psychiatry were assessed again on the 30th day of the training. Results: Mean age of the participating interns (n=47) was 25.44±1.52 and the male female ratio was 0.8. Twenty six interns did only the 15 days mandatory psychiatry internship posting (Group 1) and the remaining 21 interns took up the additional elective 15 days posting (Group 2). At the end of the 15 days posting, Mean ATP score of the group 1 increased from 88.34±6.07 to 88.46±6.19 (p=0.80) whereas the same increased from 88.04±7.06 to 88.19±7.65 (p=0.7) in the group 2 and further increased to 91.09±8.3 at the end of the additional 15 days of elective posting (p<0.05). Conclusion: A thirty days exposure of psychiatry during internship had more favourable impact on the attitude of interns towards psychiatry.


Introduction
World Health Organization's defi nition of health states mental well being as one of its essential component.Unfortunately, this component of health is being grossly neglected.As a result, mental disorders have become a leading cause of ill health and disability globally.[1] Unfortunately, there is a huge treatment gap globally, [2,3] and more so in the low income and middle income countries.[4,5] India is no exception to this state of aff airs.Year aft er year, print media is replete with frequent news items discussing the shortage of psychiatrists in India.In a population of 1.21 billion, [6] there is just one psychiatrist per 200,000 population, i.e. 0.5 psychiatrist per 100,000 population.[7,8] Th ese unmet needs cannot be fulfi lled unless we have plenty of quality psychiatrists.
Unfortunately, world over, psychiatry is not the preferred specialisation of choice among the medical graduates.[9] Jha et al. [10] did a survey among the fi rst and second year students, enquiring about the subject of choice for specialisation.Although 48.3% of the students were interested to take up nonsurgical for specialisation, only 8.1% expressed interest towards psychiatry as compared to 23.4% for paediatrics and 20.9% for cardiology.Similar results were shown by Subba et al., [11] wherein only 3.2% of students from a south Indian medical institute wanted to opt psychiatry as their fi rst choice of specialisation as against 32.2% for surgery and 22.8% for internal medicine.It is well known that the career choice depends a lot on how the student perceives the speciality and the specialists, and also on their attitude towards the subject.[12,13] Th e attitude of medical graduates towards psychiatry has always been very dismal.Th e common reasons cited are the subject being less scientifi c, variable effi cacy of treatments, and the low status of psychiatrists among other doctor colleagues.[14][15][16] Th ese attitudes need to be improved to raise the number of psychiatrists in the society.Th e common factors having an eff ect on the attitudes towards psychiatry are experience with the subject, [17][18][19] the awareness of the therapeutic potential of psychiatric interventions, the direct contact with patients, [19,20] an infl uential interaction between students and psychiatrists, [21,22] and contact with psychiatric outpatients.[20,23] In India, these factors come into play during the internship period -a period of psychiatry rotation aft er medical graduation.In a psychiatry rotation of internship, an intern usually works under the guidance of a psychiatrist and has personal contact with psychiatry patients, and can observe and understand various therapeutic interventions.A good quality psychiatry exposure during the internship has a potential to change the unfavourable attitude of medical students towards psychiatry.[22,24] However the required duration of exposure for such a change has always been a question.[25,26] Although the period of internship in psychiatry has been reduced by many countries, [27] as a pleasant change Medical Council of India (MCI) allowed the students to take up an extra 15 days of elective posting in psychiatry along with the mandatory psychiatry posting of 15 days on 20th October 2008.[28] We felt it would be worthwhile to assess the eff ect of the additional period of psychiatry internship on the attitude of intern medical students towards psychiatry.

Study design
It was a prospective questionnaire based study conducted in Department of Psychiatry at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India over a period of one year.

Inclusion criteria
All the medical interns of all ages and either gender reporting to department of psychiatry for internship posting were included for the study.

Exclusion criteria
Interns refusing to give informed consent were excluded.

Protocol
Aft er getting approval from the Institutional Ethics Committee, over a period of one year, all the interns being posted in psychiatry as a part of internship were off ered to participate in the study.All the interns were explained about the nature of the study and were explained that there was no compulsion to participate.Interns who agreed to give an informed consent were given a semi structured proforma which contained details such as age and gender, and were asked to fi ll up Attitude Towards Psychiatry (ATP) scale.ATP scale is a 30 item fi ve point likert scale constructed and validated by Burra et al., [29] wherein the participant had to mention whether he strongly disagrees, disagrees, agrees, strongly agrees, or is neutral about each of the 30 statements.Depending on the answers, each item was scored and then a total score was calculated.All the participants were asked to fi ll up the scale at the beginning of their internship posting and aft er their mandatory 15 days rotation.Some interns did not opt for the additional elective 15 days posting in psychiatry (group 1) while some opted for the same (group 2).Th ose participants who were willing to do an additional 15 days of elective posting in psychiatry were then asked to fi ll up the scale for the third time at the end of their elective posting (Figure 1).

Statistics
Means and standard deviations were used to present continuous variables.Th e ATP scores of diff erent groups were then compared by t-test.A p value of less than 0.05 was considered as statistically signifi cant.

Results
In all, 53 interns were approached.Of these, 47 consented to participate in the study.Th e mean age of the participating interns was 25.44±1.52years.Th ere were 22 males and 25 females, and male/female ratio was 0.88.Th e ATP score of 47 interns before the start of internship ranged from 72 to 103 and the mean ATP score was 86.66±6.34.Baseline mean item-wise score of medical interns across 30 items of the ATP scale was calculated (Table 1).Among all the statements, the interns were most favourable for statement "In recent years, psychiatric treatment has become very eff ective" with the item score of 3.34 and the interns were least favourable for "Psychiatric patients are oft en more interesting to work with than other patients" with the mean item score of 2.43.
Of these 47 interns, 26 interns did not say they will opt for psychiatry as an elective subject but did complete their 15 days mandatory psychiatry internship posting (group 1).Th e remaining 21 interns took up the additional elective 15 days posting (group 2).Th e mean age and the male/female ratio of group 1 and group 2 were 25.88±1.73years; 0.85 and 24.90±1.04years; 0.90 respectively (p=0.27; p=0.92 respectively).
Baseline mean ATP score of group 1 was 88.34±6.07.This increased to 88.46±6.19 after the 15 days mandatory posting, but this increase was not significant (p=0.80)(Table 2).Similarly, in group 2, the baseline mean ATP score was 88.04±7.06.This increased to 88.19±7.65 at the end of 15 days of mandatory posting.This increase was not significant (p=0.7).However, at the end of the additional 15 days of elective posting, the mean ATP score of group 2 was found to be 91.09±8.3.As compared to the baseline, the change in the ATP score after the end  of additional elective posting was found to be significant (p=0.00015)(Table 3).

Discussion
To the best of our knowledge, aft er MCI introduced the option of an additional 15 days of elective posting in psychiatry, this study is the fi rst of its kind being done to assess the eff ect of this decision.Overall, the attitude of medical interns towards psychiatry was very disappointing.Th e mean ATP score of the interns at the beginning of the study was only 86.66±6.34 as against the best possible score of 150 on the ATP scale.Th is appalling status of attitude of Indian medical graduates towards psychiatry has been frequently echoed by literature across India, both recently as well as in the past.Parikh et al. [30] did a similar study among the medical interns and found the mean ATP score to be 93.31±14.87 with a range of 46-142.Similarly, another study done by Th aryan et al. [31] also showcased the poor attitude of medical interns towards psychiatry wherein the mean ATP score was 64.17.Even the western literature frequently reports of poor attitude of medical interns and graduates towards psychiatry.A Turkish study was done on the medical graduates to assess their attitude towards psychiatry and the mean ATP score was 106.07±13.05.[32] Similarly, the mean ATP score of 71 medical students of Hungary was 109.28±11.82.[33] All these studies refl ect that the medical students' poor attitude towards psychiatry as noticed in our study is congruent to many of the studies done till date.
Among the individual items, the attitude of interns was most favourable towards the statement "In recent years psychiatric treatment has become very eff ective".Recently, the teaching of aetiological basis of psychiatry has shift ed from the classical psychodynamic concept to the biological neurotransmitter and secondary messenger concepts.[34] Th is is more in line with the understanding of other medical disorders and the biological treatments with safe and eff ective medicines.Moreover, integration of psychiatry into the general hospital setup has helped the image of psychiatry as a medical speciality.[35] As compared to past wherein the interns were mostly exposed to long term asylum patients, they are now more exposed to the acute clinic based psychiatric and psychological care, handling both psychotic as well as neurotic illnesses.Th ese two facts may be responsible for the appreciation that the interns expressed towards psychiatric treatment.
In our study, the interns had the least favourable attitude towards the statement of "Psychiatric patients are oft en more interesting to work with than other patients".Such attitudes towards psychiatric patients may have a negative impact on meeting health requirements, both general as well as psychiatric requirements, of patients with psychiatric illness.Such negative attitudes towards patients with psychiatric illness could be either due to the poor communication ability of such patients [36] or due to the associated stigma [37] or probably due to the low paying capacity of these patients in absence of insurance facilities.[38] A positive and good quality exposure of psychiatry during internship has a potential to modify the attitude of interns towards psychiatry.[22,24] Th e required duration of exposure for such a change has always been a question.In our study, a 15 days exposure of group 1 as well as group 2 did not lead to any signifi cant change in the attitude of medical interns towards psychiatry.A similar study done by Gazdag et al. [33] tried to compare the attitude of 71 medical students before and aft er the 15 days of clerkship.Before clerkship their mean ATP-30 score was 109.28±11.82which later increased to 111.08±11.94aft er the clerkship, but this increase was insignifi cant.More so, the mean score on the item "I would like to be a psychiatrist" dropped signifi cantly from 1.94±0.89 to 1.68±0.79.Similarly, Th aryan et al. [31] compared the attitude towards psychiatry of the medical students exposed to psychiatry for two weeks with those who were not.Even this study could not show any signifi cant diff erence of attitude among the students irrespective of the exposure to psychiatry.However, in group 2, a total of 30 days of exposure, including the 15 days of mandatory internship posting and 15 days of elective internship posting, led to a signifi cant  change in the attitude of medical interns towards psychiatry.Wilkinson et al.[17] also demonstrated a signifi cant improvement in the attitude of medical students aft er an eight weeks clerkship and this improvement was maintained even aft er one year.Lyons et al. [39] attempted to study the medical students' attitude towards psychiatry across the eight weeks clerkship period using the Balon Attitudes Towards Psychiatry questionnaire.[40] Th ey found that their attitude towards mentally ill patients improved signifi cantly aft er the eight weeks of clerkship.Bulbena et al. [41] showed that a psychiatry exposure of a total of 100 hours (six weeks during the fourth year), 35 hours of theory lessons, and 65 hours of practice rotation helped in improving the attitude of medical students towards psychiatry, especially in the domains of "overall merits of psychiatry", "possible abuse and social criticism", " career and personal reward".
Th ere has always been competition for time from other medical specialities, and this has not let the medical students receive adequate exposure to psychiatry, thereby aff ecting their knowledge of psychiatry.[25][26][27] Th is also undermines the importance of the subject and leads to a probable negative impact on their attitude.An adequate positive experience during the students' internship is one of the important factors leading to a positive impact on their attitude towards psychiatry.If they have a good, eff ective, and suffi cient exposure, it will improve their attitude towards psychiatry and will increase the likelihood that they may opt for psychiatry as a subject of specialisation.[42] Considering the results of our study, the policy of MCI to give an option of additional 15 days of posting in psychiatry as an elective in addition to the mandatory 15 days of internship posting is a welcome step in this regard.Such eff orts will go a long way in improving the attitude of medical interns towards psychiatry and thereby encouraging them to take up psychiatry as a specialisation.

Conclusion
A 30 days exposure of psychiatry during internship had more favourable impact on the attitude of medical interns towards psychiatry as compared to a 15 days exposure.Th e off ering of an additional 15 days of elective posting in psychiatry by the MCI is a positive step in this regard.More and more interns should be encouraged to opt for the additional 15 days of elective posting in psychiatry.

Table 1 :
Mean item-wise score of each of the statement of attitude towards psychiatry (ATP) scale (Contd...)

Table 2 :
Mean ATP scores of group 1 at baseline and after 15 days of mandatory psychiatry internship posting

Table 3 :
Mean ATP scores of group 2 at baseline, after 15 days of mandatory psychiatry internship posting, and after additional 15 days of elective posting