Recruitment Into Psychiatry: Increasing the Pool of Applicants

Walter Weintraub, MD1, S Michael Plaut, PhD2, Eric Weintraub, MD3


Objective: To demonstrate that it is possible to identify the cohort of students in their first year of medical school from which future psychiatrists will be recruited.

Method: During a 3-year period, all first-year medical students at the University of Maryland completed a form indicating their specialty preference. Of those students, 403 pursued the regular psychiatry curriculum, and 34 participated in an enriched behavioural science and psychiatry program. Specialty was chosen after graduation.

Results: The higher the first-year student ranked psychiatry as a preferred specialty, the more likely the student was to choose psychiatry as a career after graduation. This was true both for students in the regular psychiatry program and for those in the enriched program. Students in the enriched program were significantly more likely to choose psychiatry as a career than were “regular” psychiatry students who gave psychiatry the same ranking in their first year. Freshman students who ranked psychiatry 4th or lower were not likely to choose psychiatry, no matter how much encouragement they received from their psychiatry departments.

Conclusions: 1) Specialty preferences in the freshman year are predictive of future career choices. 2) An enriched medical school program in psychiatry can increase the number of graduates choosing careers in psychiatry. To help resource-poor medical schools increase the number of American medical graduates choosing psychiatry, the authors propose 2 inexpensive enriched programs.

(Can J Psychiatry 1999;44:473–477)

Key Words: residency, recruitment, increasing the pool of applicants, identifying future psychiatrists, medical school, the Combined Accelerated Program in Psychiatry

With psychiatry in the United States (US) continuing to have problems recruiting American medical graduates (AMGs), educators have speculated about possible solutions to the recruitment difficulty. Recommendations from 2 psychiatric recruitment conferences have emphasized the importance of medical student teachers, decisions of admissions committees, psychiatry’s image, federally funded incentives (1), and “psychiatrically oriented” medical students (2,3).

Some educators have noted the economic factors that contribute to the recruitment difficulty, such as students being attracted to high-paying specialties to pay off student loans (4,5), avoiding specialties with few job opportunities (6), and feeling the financial pressures of managed care (7). There is no evidence, however, that the psychiatric profession can influence political and economic factors in any significant way.

Certain educators assume that more students enter medical school planning careers in psychiatry than actually join the profession after graduation. The reasons for the “defections” are believed to be due to an unfriendly medical school environment (8,9). Psychiatry tends to be viewed in a consistently negative way by nonpsychiatric faculty and house staff. Why not use the resources of psychiatry departments to create a supportive environment for students interested in psychiatry? In a recent article, we presented data showing recruitment success over a 20-year period among students participating in an enriched psychiatric program (10). This program, the Combined Accelerated Program in Psychiatry (CAPP), contains many of the elements believed to encourage students to choose careers in psychiatry (11).

This report shows that the cohort of students from which future psychiatrists will be recruited can be identified in the first year of medical school. The process of identifying the cohort takes less than 5 minutes and consists of completing a specialty-preference form. We demonstrate an association between the order in which psychiatry is ranked and the likelihood of the student choosing psychiatry after graduation. We also show that a student’s intention to choose a career in psychiatry can be reinforced by appropriate medical school electives. Once likely future psychiatrists are identified, a program can be developed to check the erosion of interest in psychiatric careers.

The CAPP

The CAPP was initiated by the Department of Psychiatry of the University of Maryland in 1970. Each year 12 freshman students are selected from approximately twice that number of applicants. A student’s chances for acceptance to the program are enhanced if he or she has an unusually brilliant college record, has a special accomplishment (PhD, published research), belongs to a minority group, or comes from rural Western Maryland or the Eastern Shore.

CAPP students attend reading seminars during the first 2 years of medical school to help them master basic psychiatric concepts. The clinical part of the program is highly structured and comprises a sequentially arranged series of experiences through which all participants must pass. During the first semester of the freshman year, CAPP students are taught how to establish rapport with interviewees, using first each other and then ward patients as subjects. During the second semester, students learn to elicit and describe the signs and symptoms of psychiatric illness. Students also spend 4 hours weekly on a psychiatric ward, where they become familiar with a ward community and submit mental status reports, which are corrected by a faculty member. CAPP students who desire personal therapy are offered treatment by the local psychoanalytic society at a fee they can afford.

During the summer following the freshman year, CAPP students spend 2 months on a psychiatric ward. They are generally integrated into the junior psychiatry rotation of the institutions in which they train. They receive modest stipends and are free to fulfil this requirement anywhere in the world. CAPP students have done so in England, Italy, Switzerland, and Turkey.

Supervised psychotherapy with adults and children begins in the second year of medical school. Students attend a continuing case seminar and receive individual supervision from faculty members.

CAPP students are given preference by the Department of Psychiatry when applying for fellowships and jobs, are invited to professors’ homes to socialize, and often develop close relationships with faculty members (12,13).

Full-time and part-time faculty do most of the teaching free of charge. Summer stipends are provided by those institutions to which the students are assigned. Departmental funds provide stipends for students choosing to leave the Baltimore–Washington area.

Psychiatric Training for Non-CAPP Students

During the 20-year period covered by this report, the Department of Psychiatry offered a strong undergraduate program for non-CAPP students comprising 150 hours in the preclinical years and a 6-week clerkship combining outpatient and inpatient assignments in the clinical years.

Data Collection

Within 2 weeks after the beginning of freshman classes, CAPP students complete a specialty-preference form. Between 1974 and 1993, 20 groups of students entered residency training programs. Only students who completed at least 1 year in the CAPP have been included in the study; the possible positive effects of the program are not likely to be significant for students who spend only a few months in the program. Of 244 students admitted into the CAPP during the 20-year period, 222 filled out the entire specialty-preference from, completed at least 1 year in the program, and graduated from medical school. Of these 222 students, 98 preferred psychiatry, 45 ranked psychiatry 2nd, 34 chose psychiatry 3rd, and 45 ranked psychiatry 4th or lower.

In 1972, 1973, and 1974, all freshman students were asked to complete the specialty-preference form given to CAPP students. Of the 446 non-CAPP students, 403 completed the specialty-preference form and graduated from medical school. Of the 403 students, 20 preferred psychiatry, 30 chose psychiatry 2nd, 66 ranked psychiatry 3rd, and 287 selected psychiatry 4th or lower.

By means of phone calls and records kept by the Alumni Office and the Office of Student Affairs, we were able to ascertain the specialty choices of the 222 CAPP students and the 403 non-CAPP students in the classes of 1976–1978.

Results

Freshman Specialty Rankings Predict Future Career Choices

Tables 1 and 2 show that the higher students ranked psychiatry in their freshman year, the more likely the student was to choose psychiatry as a career. This was true for both CAPP and non-CAPP students. Of 98 CAPP students who ranked psychiatry 1st between 1970 and 1989, 68 (69.4%) entered psychiatric residency training programs. Of those who ranked psychiatry 2nd, 3rd, and 4th or lower, respectively 14 of 45 (31.1%), 9 of 34 (26.5%), and 3 of 45 (6.7%) (c2 = 58.65, df = 3, P < 001) entered such programs.

Table 1. Ranking of psychiatry by first-year students who chose psychiatric careers (1974–1993)


Rank

First-year preference (n = 222)

Graduate selection
(n = 94)


%

1

98

68

69.4a

2

45

14

31.1

3

34

9

26.5

4 or lower

45

3

6.7

ac2 = 58.65, df = 3, P < 0.001.

Table 2. Ranking of psychiatry by first-year students who chose psychiatric careers (1976–1978)

 

CAPP students

Non-CAPP students



Rank

First-year preference
(n = 34)

Graduate selection (n = 17)



%

First-year preference
(n = 403)

Graduate selection (n = 11)



%

1

16

13

81.3

20

3

15.0a

2

11

3

27.3

30

4

13.3

3

2

1

50.0

66

1

1.5

4 or lower

5

0

0.0

287

3

1.0

ac2 = 7.57, df = 1, P < 0.01.

Freshman ranking had predictive power for non-CAPP students (1976–1978) too. Three of 20 who ranked psychiatry 1st (15%) chose psychiatric careers. The figures for non-CAPP students ranking psychiatry 2nd, 3rd, and 4th or lower are 4 of 30 (13.3%), 1 of 66 (1.5%), and 3 of 287 (1.0%) ( c2 = 7.57, df = 1, P < 0.01) respectively.

Enriched Undergraduate Program Reinforces Interest in Psychiatry

A strong interest in psychiatry may erode if not reinforced by psychiatry departments. Between 1974 and 1993, 68 of 98 (69.4%) CAPP graduates who ranked psychiatry 1st in their freshman year entered psychiatric residency programs after graduation. Thirteen of 16 CAPP students in the classes of 1974–1976 who ranked psychiatry 1st chose psychiatric careers. For 1974–1976, 3 of 20 (15%) non-CPP students did so (c2 = 15.43, df = 1, P < 001).

For a medical student to enter the pool of applicants, he or she as a freshman must have ranked psychiatry among the top 3 specialties (Tables 1 and 2). Very few students who ranked psychiatry 4th or lower entered psychiatric residency training. This was true even for CAPP students. Over a 20-year period, fewer than 10% of CAPP students who ranked psychiatry 4th or lower chose psychiatric careers. The likelihood that non-CAPP students who ranked psychiatry 4th or lower would choose psychiatric careers was about 1%.

Discussion

Let us summarize our findings: 1) By means of a specialty-preference form, it was possible to identify most first-year University of Maryland CAPP students who would choose careers in psychiatry between 1974 and 1993. Of the 94 CAPP students who entered psychiatric residency programs, 91 (96.8%) ranked psychiatry among their first 3 specialty choices early in the freshman year. Of 11 non-CAPP students in the classes of 1976–1978 who chose psychiatric careers, 8 (72.7%) ranked psychiatry among their first 3 choices. 2) Our data show that most non-CAPP students who ranked psychiatry among their first 3 choices chose nonpsychiatric careers. 3) Few freshman students who ranked psychiatry 4th or lower chose psychiatric careers. 4) The CAPP appears to reinforce medical students’ initial interest in psychiatric careers. The importance for recruitment of reinforcing initial interest in psychiatry has been stressed by several educators (14–16).

CAPP Influence on Recruitment

Discussions with CAPP students suggest the following aspects of the program as important in recruitment: 1) small group teaching, 2) early patient contact, 3) association with senior psychiatric faculty, 4) low-cost therapy, 5) association with students sharing an interest in psychiatry, 6) focus on the doctor–patient relationship, 7) opportunity to test one’s aptitude for psychiatry, 8) contact with charismatic house staff, 9) early contact with child and adolescent patients, and 10) gratification from belonging to a pampered, elite group. Early patient contact and association with senior faculty were mentioned most often by CAPP students.

Comparison of CAPP Students with Non-CAPP Students Preferring Psychiatry

In making our statistical comparisons, we have assumed that first-year CAPP students preferring psychiatry can be compared to non-CAPP students preferring psychiatry. Is it not likely that students willing to spend extra time to learn psychiatry are more serious in their freshman career choice of psychiatry than students not prepared to make such an effort? In a previous publication (17), it was shown that a group of rejected applicants to CAPP who preferred psychiatry were no more likely to choose psychiatric residencies than nonapplicants to CAPP preferring psychiatry.

Administrative Obstacles to CAPP?

Colleagues frequently ask us about the need to obtain approval from the dean and medical school curriculum committees in order to schedule CAPP activities. This has not been a problem at the University of Maryland. The CAPP is entirely extracurricular. CAPP students are not excused from any part of the regular curriculum. CAPP seminars and clerkships are scheduled during the students’ free time.

Can the CAPP Endure in Today’s Climate?

To what extent have recent changes in the psychiatric profession made the CAPP obsolete? Do students still volunteer to participate in the program? Can faculty be recruited for volunteer teaching? Does the CAPP continue to shelter students interested in psychiatric careers from the stigmatizing effects of medical school?

The following facts speak for themselves: 1) The CAPP curriculum, which emphasizes the doctor–patient relationship, is almost the same as it was when the program began in 1970. 2) Faculty members, some of them former CAPP students, continue to do most of the teaching on a volunteer basis. 3) Students continue to apply to the program in large numbers. More than 15% of the class entering medical school in 1996 applied to the CAPP (23 of 142 students). 4) Seven of 12 CAPP students in the class of 1996 applied to psychiatric residency programs. Four of those 7 ranked psychiatry 1st in their freshman year. Only 1 CAPP student who ranked psychiatry 1st applied to a nonpsychiatric residency program.

The Importance of Increasing the Pool of Applicants

Certain colleagues discount the importance of increasing the pool of AMG applicants to psychiatric residency programs. They believe that fewer psychiatrists may be needed in the future and that, in any case, enough international medical graduates are available to compensate for the shrinkage of the US pool. In Canada, provincial governments regulate the total numbers of specialists. Does not this practice make the recruitment problem less serious? Yager and Borus have written that psychiatry needs fewer but better-trained practitioners (18). It is clear, however, that the quality of US psychiatrists will not be improved by shrinking the pool of applicants. Regulating the number of Canadian specialists does not guarantee that psychiatry will fill its matched positions. The larger the pool of applicants, the higher the quality of graduates recruited into the profession. In a recent publication, we showed that the CAPP has succeeded in recruiting into psychiatry some of the top University of Maryland graduates since 1974 (10).

Data provided by the CAPP and other undergraduate programs demonstrate that psychiatry departments can help enlarge the pool of applicants to psychiatric training programs (5,8). Although the exact formula for successful recruitment is not known, certain factors are common to most programs that report favourable results; that is, involvement of senior faculty, small-group teaching, and early patient contact. High-quality clinical clerkships that offer outpatient as well as inpatient experience may help counter the erosion of medical students’ interest in psychiatry.

Increasing the Applicant Pool “On a Shoestring”

How can a resource-poor psychiatry department reinforce medical students’ interest in psychiatric careers? We propose the following 2 programs as inexpensive and possibly effective. They contain several educational strategies developed by the CAPP, which require few resources. Plan A is exclusive, Plan B inclusive.

Plan A

1. Administer a specialty-preference form to all first-year medical students at the start of the first semester.

2. Identify those students who rank psychiatry among their first 3 specialty choices.

3. Encourage interested students who rank psychiatry high to volunteer for a special undergraduate program.

4. Teach these volunteer students separately during their first and second years. Involve senior psychiatric faculty, if possible.

5. Undergraduate program should focus on the doctor–patient relationship, using live interviews with psychiatric patients.

6. Quarterly academic or social gatherings should be held, preferably in the homes of psychiatric faculty.

7. Program participants should be assigned to the most desirable clinical clerkships in their third and fourth years.

8. Program participants should be assigned to the most charismatic psychiatric residents during their clinical clerkships.

We estimate that the total cost of Plan A should not exceed a few thousand dollars yearly. A course in conducting interviews in the first year and a psychopathology course with actual patients in the second year should be all the additional teaching that is required.

Plan B

For those psychiatry departments that do not wish to divide the undergraduate students into 2 groups, we propose the following program, which is even simpler and less costly than Plan A. It is currently in use at the University of Maryland for those medical students interested in psychiatry but unwilling to devote the amount of time required of CAPP students.

Plan B is directed by a junior faculty member who has a special interest in undergraduate education. Once every month, all interested medical students are invited to hear a speaker on a topic related to psychiatry and the behavioural sciences. Lunch is served, and the cost is defrayed by the psychiatry department. Attendance varies depending upon the speaker and the topic. As many as 60 students have attended the more popular meetings. The annual budget for the program is $2000.

Key Recruitment Elements of Plans A and B

Of the various elements of Plans A and B, it is difficult to pinpoint those that are particularly useful in recruiting medical students into psychiatric residency program. Comments by participating students suggest that patient contact and association with psychiatric faculty are probably the most important recruitment factors.

Clinical Implications

Limitations

References

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4. Rosenthal MP, Diamond JJ, Rabinowitz HK, Bauer LC, Jones RL. Influence of income, hours worked and loan repayment on medical students’ decision to pursue a primary care career. JAMA 1994;271:914–7.

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6. Kassebaum DG, Szenas PL. Specialty intentions of 1995 US medical school graduates and patterns of generalist career choice and decision making. Acad Med 1995;70:1152–7.

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9. Bruhn JG, Parsons OA. Attitudes toward medical specialties: two follow-up studies. Journal of Medical Education 1965;40:273–80.

10. Weintraub W, Plaut SM, Weintraub E. Medical school electives and recruitment into psychiatry: a 20-year experience. Academic Psychiatry 1996;20:220–5.

11. Kaltreider NB, Lu FG, Thompson TL. Student education and recruitment into psychiatry. Academic Psychiatry 1994;18:154–61.

12. Balis GU, Weintraub W, Mackie J. A four-year behavioral science-psychiatry track in undergraduate medical education. Journal of Medical Education 1974;49:1051–6.

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Résumé

Objectif : Démontrer qu’il est possible de reconnaître la cohorte d’étudiants de première année de médecine au sein de laquelle les futurs psychiatres seront recrutés.

Méthode : Au cours d’une période de 3 ans, tous les étudiants en médecine de première année de l’Université du Maryland ont rempli un formulaire, indiquant leur préférence en matière de spécialité. Parmi ces étudiants, 403 suivaient le programme régulier d’études en psychiatrie, et 34 participaient à un programme enrichi de science du comportement et de psychiatrie. Le choix de la spécialité s’effectuait après l’obtention du diplôme.

Résultats : Plus l’étudiant de première année accordait un rang élevé à la psychiatrie comme spécialité préférée, plus il était susceptible de choisir la psychiatrie comme carrière après les études de premier cycle. Cela se vérifiait tant pour les étudiants inscrits au programme régulier de psychiatrie que pour ceux du programme enrichi. Les étudiants du programme enrichi étaient considérablement plus susceptibles de choisir la psychiatrie comme carrière que les étudiants « réguliers » en psychiatrie, qui accordaient le même rang à la psychiatrie en première année. Les étudiants de première année qui classaient la psychiatrie au quatrième rang ou moins n’étaient pas susceptibles de choisir la psychiatrie, peu importe à quel point ils y étaient incités par le département de psychiatrie.

Conclusions : 1) Les préférences en matière de spécialité en première année sont prédictives des futurs choix de carrière. 2) Un programme d’études enrichi en psychiatrie peut augmenter le nombre des diplômés qui choisissent la psychiatrie comme carrière. Pour aider les facultés de médecine aux ressources limitées à augmenter le nombre de diplômés en médecine américains qui choisissent la psychiatrie, les auteurs proposent 2 programmes enrichis peu coûteux.

Manuscript received April 1998, revised, and accepted September 1998.

1Clinical Professor, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland.

2Associate Professor, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland.

3Assistant Professor, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland.

Address for correspondence: Dr W Weintraub, University of Maryland School of Medicine, 701 West Pratt Street, 4th Floor, Baltimore, MD 21201

Can J Psychiatry, Vol 44, June 1999