Impact of psychiatry clinical rotation on attitude of interns towards psychiatry

Background: Internship is a vital phase in medical student’s training which can have a bearing on the attitude they develop towards various specialities. Limited studies have tried to assess the effect of clinical rotation on the attitude of interns towards Psychiatry. This study was planned to assess the same before and after a 2 week posting in Psychiatry. Aim: To study the change in attitude of interns towards Psychiatry before and after clinical rotation in Psychiatry. Materials and Methods: The study sample comprised of 100 interns in a tertiary care teaching hospital. Written informed consent was taken from the interns before the study. Appropriate ethical approval procedures were followed while taking consent from subjects and also in conducting the research. Attitude towards Psychiatry-30 was used to assess the attitude of interns towards Psychiatry before and after a 2 week Psychiatry rotation. Semi structured questionnaire was filled by interns regarding socio-demographic details and views about psychiatry. Non parametric tests were used to analyze the data obtained using SPSS software. Results: This study showed favourable improvements in the ATP-30 score following exposure to the clinical rotation. There was a statistically significant change in mean difference of total global ATP 30 scores in males and females. Female gender found to have more positive attitude than males. The responses to 11 statements from ATP -30 scale showed statistically significant improvement after the posting. Conclusion: The attitude of interns towards Psychiatry improved following a 2 week clinical rotation in Psychiatry. Further studies are needed to better understand the factors that may influence the attitude of interns.


Introduction
The overall weighted prevalence for any mental morbidity was 13.7% lifetime and 10.6% current mental morbidity in the National Mental Health Survey of India 2015-2016 1 Alarming finding was that the treatment gap for mental disorders ranged between 70% and 92% for different disorders. 2 The World Mental Health Atlas 2014 mentions the number of psychiatrists in India as 0.30 per 100,000 population, while the desirable number is around above 3 Psychiatrists per 100, 000. 3 Considering this as the desirable number, 36,000 is the number of psychiatrists required to reach that goal. India is currently short of 27,000 doctors based on the current population of country. 3 Data available showed the shortage of psychiatrist is varied and improvement is not uniform in the country. 3 According to NMHS 2015-2016, Kerala had 1.2 psychiatrists per 100,000 population. 1 The alarming shortage of number of psychiatrists can be estimated from the fact that all the other states fall short of 1-2 psychiatrist per 100,000 population which is the minimum requirement. 1 Therefore, it is absolutely vital that more and more young doctors need to be trained as psychiatrists to bridge the gap. For that to happen effectively, a positive attitude towards psychiatry needs to be developed among medical students and young doctors besides increasing the opportunities available for training.
Internship is a vital phase during medical student's life and exposure to different specialities during this tenure is a good opportunity to understand student's inclination towards a specialty for future. Factors like personality, previous experience with a person with mental illness and influence of faculty members of psychiatry have been found to affect the attitude of medical students towards psychiatry. 4 It is noteworthy that psychiatry patients have been stigmatised by society since ages and depicting the psychiatry ailments as violent, unpredictable and dangerous have contributed to stigma and this negative attitude. 5 Such a negative attitude has been reported even in medical students which is a major point of concern. 6 Such a negative attitude will, besides influencing students' future career choices, affect the care of psychiatry patients when dealt by other specialists at some point of time in their career. [7][8][9][10][11] Therefore immediate attention towards destigmatization is the need of the hour. The medical curriculum in most Indian Universities provides a rotation of varying duration in psychiatry during internship. During the rotation they are expected to evaluate and manage the patients under the supervision of senior faculty. Building a positive attitude during this short duration may lead to more students opting for psychiatry as specialization. 12 Understanding the impact of psychiatry clinical rotation on interns' attitude may give us valuable insight to further improve the current scenario. In our hospital, interns during the mandatory two week posting get adequate exposure in OPD and attend daily rounds of in-patients along with post graduates and consultants. Every intern posted in psychiatry gets an equal opportunity on the 24 hours duty to tag along the post graduates and consultants to see referrals from other departments. They get invaluable exposure to consultationliaison psychiatry and imbibe the knowledge to manage psychiatry patients with co-morbidities. They, during the 24 hours on call day, attend the Emergency calls along with post graduates and consultants and learn to manage psychiatry patients in crunch situations.
Besides, they accompany the post graduates and consultants for the ECT sessions which help them resolve the myths about the shock therapy. Apart from such vast clinical exposure, interns also attend the seminars, case presentations and journal clubs held during the academic session daily along with post graduates and consultants. Daily attempts are made to add to their psychiatry knowledge so as to enable them to have a positive attitude towards psychiatry.
Existing literature is limited as few studies have been conducted in India to assess the attitude of medical students or interns towards psychiatry and results have been conflicting. Most of the previous studies have assessed the attitude in general without considering the impact of clinical rotation in psychiatry. A study has shown overall favourable attitude towards psychiatry patients when compared with medical patients. 13 Few other studies have shown that such short duration was not sufficient to influence the attitude towards psychiatry significantly. Another study reported changes in certain aspects of attitude towards psychiatry patients. 14 With this background, the current study was conducted to assess the impact of a 2 week clinical rotation on the attitude of interns towards psychiatry.

Materials and Methods
The present study is a cross sectional study done at the department of Psychiatry of ***** Institute of Medical sciences over a period of 12 months. It is a tertiary care teaching hospital located in city ***** of **** state. The Institutional Ethical committee clearance was obtained before starting the data collection. We examined the effects of two week psychiatry posting of House surgeons in their attitude towards psychiatry. After explaining them the aim of the study and obtaining their informed consent, participants filled up the semi structured socio demographic profile. The questionnaire did not include any identifying information and participants were asked to drop the folded questionnaires into a designated box, whether completed, partially completed or not filled up at all, ensuring the students' anonymity. A standardized and structured questionnaire, Attitude Towards Psychiatry (ATP 30), was offered to all participants (n =100) on the first and last day of clinical rotation in psychiatry. All 100 house surgeons returned the completely filled up questionnaires before and after the psychiatry posting.
ATP 30 is a 5-point Likert-type scale designed and validated in Canada by Burra et al. 15 The scale consists of thirty positively and negatively phrased items that measure the strength of the respondent's attitude to various aspects of psychiatry. A score of 1 denotes a highly positive attitude, 5 denotes a highly negative attitude and 3 denotes a neutral response. The score of each positively phrased item is converted by subtracting it from 6. The ATP score is the sum of total scores for positive and negative phrased items. The total global score ranges from 30 to 150. A total global score of < 90 suggests a negative attitude towards psychiatry, > 90 suggests a positive attitude towards psychiatry while a global score of 90 is considered to represent a neutral attitude. Each question of ATP-30 was analyzed independently and thematically with groups of questions together. The responses were recorded and the data so obtained was analyzed using SPSS version 21.For discussion purpose the questions in the ATP questionnaire have been divided under the following headings. a) Attitude towards patient and illness b) Attitude towards knowledge and teaching c) Attitude towards psychiatry treatment and hospitals d) Attitude towards psychiatry and psychiatrists.
Results 100 house surgeons, females (n = 51) and males (n = 49), completed both the semi-structured questionnaire and ATP-30.The pre-posting overall mean ATP-30 score was 90.17 (SD = 9.62) and 22 students scored below the neutral point (90) indicating negative attitude towards psychiatry. The post-posting overall mean ATP-30 score was 120.35 (SD = 15.90) and only 9 students scored below neutral point. The difference in overall mean ATP-30 scores was statistically significant (p<0.05).The mean of Female and Male students pre-posting were 91.82 and 88.44. The post posting mean of Female and Male students increased to 121.58 and 119.06 which was a statistically significant improvement in attitude towards psychiatry. Besides four positively framed and seven negatively framed ATP-30 statements (total = 11) showed statistically significant change after the two weeks posting in psychiatry rotation (p<0.05).None of the statements showed change in negative direction.
Of the 100 interns who also completed semi-structured questionnaire, 70% of the interns think psychiatrists make lesser money than other specialists. 65% interns marked psychiatrists are not valued equally as other specialists in the society. Alarmingly, 81% interns think their family members would not allow them to pursue psychiatry as PG course even though 88% marked in favour of need of more psychiatrists in the country. 98% interns think Mental Health in India needs to be focussed upon and 85% marked implying that the scope of psychiatry in India is not bright. 76% interns think psychiatry patients are mismanaged by other specialties [ Table 1]. Results of the ATP questionnaire are included in Table -2,3,4,5

Discussion
This study showed a relative positive attitude towards psychiatry before two week psychiatry rotation which can be attributable to the way the subject is taught during the undergraduate days. In the fourth semester all students have compulsory two week clinical rotation in the department of psychiatry. Ten students will be posted at once, where students are taught how to communicate with the patient and how to elicit history and symptoms from the patients. During this period they are asked to work up cases and discuss it with the faculty. Besides this, twenty four hours of lecture time spread across six months is included in the sixth semester.
Among the hundred responses to the semi-structured questionnaire, 88% reported yes to "Do you think India needs more psychiatrist?" Surprisingly, only 23% reported to agree with Item number 4 of ATP-30 "I would like to be a psychiatrist" after the posting. This can be attributed to the fact that the interns think psychiatrists earn lesser money than other physicians, are respected lesser, do not have a bright future and their parents won't allow them to pursue Psychiatry as post graduation course as shown by their responses to the semi-structured questionnaire[ Table 1]. This clearly implies that the interns understand the need for more Psychiatrists in the country but are themselves reluctant to pursue their career in Psychiatry. In a study conducted in Nigeria, the positive impact of clinical rotation on attitude towards psychiatry did not translate into their intention to specialize in psychiatry. 4 In one study conducted in Spain which administered "Balon et al questionnaire", the percentage of students willing to choose psychiatry as their profession showed an increase from 4.2% before the psychiatry posting to 10.4% after the posting. 8

Attitude towards patient and illness [Table 2]
We found that the interns showed positive attitude towards psychiatric patients and illnesses as 96% agreed that psychiatric patients are human just like other people.39.5% agreed after posting that it is interesting to unravel the cause of psychiatry illnesses which was statistically significant (p<0.05).This shows that stigma towards Psychiatry patients has reduced among interns but still the students are not willing enough to consider as their career choice. In an Indian study conducted among medical students and interns, Beliefs towards Mental Illness scale (BMI) and Attitudes to Mental Illness Questionnaire (AMIQ) were used. Females constituted 99% of the subjects and interns showed more positive attitude towards psychiatry patient and illness than medical students. 13

Attitude towards knowledge and teaching [Table 3]
In this area, all interns agreed that psychiatry is the important part of the curriculum. 81.9% agreed after the posting that their psychiatry undergraduate training has been valuable (Item 10). After the posting, 73.8% disagreed that "Psychiatry has very little scientific information to go on (Item 13). Most of the interns disagreed after the posting to "Psychiatry is so amorphous that it cannot really be taught effectively (Item 30)" showing that they had better understanding of the subject after the posting. Results of our study are encouraging in comparison to various studies conducted in Pakistan and Sri Lanka. 16,17 Attitude towards Psychiatric treatment and hospitals [ Table 4] Further, students showed positive attitude towards psychiatric treatment and hospitals. Only 13% agreed to "With the form of therapy now at hand, most psychiatric patients improve (Item-14)" before posting which after the posting changed to 73.6% which was statistically significant (p<0.05). After the two week rotation, 79.27% agreed that in recent years psychiatric treatment has become effective, almost all interns disagreed that psychotherapy is fraudulent and disagreed that psychiatric treatments cause patients to worry too much about their symptoms which were statistically significant. This significant improvement in their attitude can be attributed to the direct exposure of Interns to the management of the patients during the rounds and observing the improvement in them. These results are contradictory to the results showed by the study conducted in Bahrain and Nigeria which showed that there was no significant change in beliefs and that greater exposure to psychiatry changes the attitude of medical students. 18,19 Attitude towards Psychiatry and psychiatrists. [ Table 5] After the posting, interns had better understanding about how psychiatry treatment improves all the domains of patient's life. Existing literatures shows inconsistent findings.Yadav et al found that continuous education and training improved the attitude of medical students towards psychiatry patients. 13 On the contrary, Rajagopalan M et al showed that 2 weeks exposure to Psychiatry as per the current curriculum was not sufficient to significantly influence students' attitude in a positive direction. 19 In this study, results showed how vital is the Psychiatry clinical rotation in the curriculum as it improved their attitude significantly. Such a negative attitude before the posting can be subjected to ridiculous stereotypic comments and remarks by none other than medical practitioners belonging to other specialty branches. Al-Ansari et al reported the same issue in their study in 2002. It is not uncommon to find medical teachers suggesting poor public image of a psychiatrist. Remarks like psychiatrists do nothing more than prescribing sedatives and tranquilizers and their job is neither intellectually stimulating nor financially rewarding are commonly heard. It has also has been suggested that psychiatrists themselves are more susceptible to develop psychiatric disorders. 20 To reduce this prevailing stigma globally and to make Psychiatry a preferable career option some remedies and possible interventions could be suggested. Duration of psychiatry posting should be increased rather than curbing it. Students will come to fully appreciate the work done by psychiatrists through their in depth exposure to the field. Students should be exposed to different subspecialties such as child psychiatry, addiction psychiatry, geriatric psychiatry and sleep and headache clinics. Emphasizing on the nature, prognosis and treatment of psychiatric illnesses having more chances of relapse such as substance dependence and schizophrenia can change their negative perception that psychiatrists cannot do much about their patients. Psychiatry should be introduced to the students in an innovative way. Demonstrating neurobiological basis of psychiatric illnesses with the help of modern neuro-imaging techniques in under graduation can create positive perception of Psychiatry. 21 The limitations of this study include small sample size and inclusion of interns from one medical institution only. Therefore it is suggested that a study with larger sample having heterogeneous properties of subjects from different medical colleges across the country may be carried out or similar study may be conducted in the rest of the country to show the overall impression of the country. Besides, this improvement in attitude towards psychiatry might be a temporary change as the attitude was reassessed immediately after the commencement of the posting. To counter this limitation, studies assessing attitude towards psychiatry after a year or more after the psychiatry clinical rotation is completed can be conducted which will examine the long term effect of the clinical rotation.

Conclusion
The main aim of the study was to highlight the growing need for psychiatrist in our country; since the doctor patient ratio is very low. Our study showed that even though the stigma towards psychiatry and mentally ill patients was less in interns but still they were not willing to take it as a speciality. If the current National Medical commission takes steps to de stigmatise psychiatry and increase awareness among students, more students will consider taking Psychiatry as their profession.

Source of Funding
Nil.