Introduction
Medical students, throughout their education, are influenced by many factors when it comes to their choice of career specialty (Chang et al. Reference Chang, Hung, Wang, Huang and Chang2006; Levaillant et al. Reference Levaillant, Levaillant, Lerolle, Vallet and Hamel-Broza2020). They must consider which specialties interest them, suit their personalities, and in which they can envisage developing a career. Making an under-informed choice regarding choice of speciality can lead to job dissatisfaction and potentially negatively impact patient outcomes, service development and increase the risk of burnout for the doctor (Wainwright et al. Reference Wainwright, Harris and Wainwright2019). One of the major roles of medical education is to prepare students to make informed choices about their career options. The provision of unbiased data on each specialty (theoretical and clinical) can support this. Clinical rotations additionally expose students to the behaviours, attitudes, cultures and stereotypes that exist within the medical specialities; also known as the ‘hidden curriculum,’ (Lawrence et al. Reference Lawrence, Mhlaba, Stewart, Moletsane, Gaede and Moshabela2018; Sarikhani et al. Reference Sarikhani, Shojaei, Rafiee and Delavari2020) and this exposure is likely to have a significant impact on medical students‘ career choices. Specifically, students’ experience on clinical rotations can bias their perspectives of different medical specialities (Pianosi, et al. Reference Pianosi, Bethune and Hurley2016; Spooner et al. Reference Spooner, Pearson, Gibson and Checkland2017).
‘Banter’ or ‘badmouthing’ towards medical specialties among doctors and medical students is a long-accepted reality and occurs across hospitals and medical schools. It is often centred around stereotypes of specialties and has been conceptualised with the acronym BASH: badmouthing, attitudes and stigmatisation within healthcare (Ajaz et al. Reference Ajaz, David, Brown, Smuk and Korszun2016). For the purpose of our study, we described it as ‘non-constructive criticism’ of specialties, made by medical staff or students. This phenomenon of banter or disparaging comments has previously been noted in a small number of studies as a factor influencing students’ perceptions of medical specialties and their thoughts about working within them (Ajaz et al. Reference Ajaz, David, Brown, Smuk and Korszun2016; Baker, et al. Reference Baker, Wessely and Openshaw2016; Spooner et al. Reference Spooner, Pearson, Gibson and Checkland2017). For example, a survey of medical students in 13 universities in the United Kingdom (UK) noted that general practice and psychiatry were the most frequently criticised specialties, and that 27% of students attributed their change of career choice to this criticism (Ajaz et al. Reference Ajaz, David, Brown, Smuk and Korszun2016), replicating findings from an earlier study of medical students in the United States (US) (Holmes et al. Reference Holmes, Tumiel-Berhalter, Zayas and Watkins2008).
There are no previous studies in Irish medical schools assessing the occurrence of badmouthing of specialties and whether this impacts on students’ career choices. We aimed to collect information on Irish medical students’ experiences of hearing non-constructive criticism of specialties. Specifically, we sought to measure a) the proportion of medical students exposed to: a) non-constructive criticism of different specialties b) criticism of specialties based on seniority of academic or clinical staff and c) if negative commentary influenced student career choices in relation to psychiatry specifically and d) general attitudes of medical students towards psychiatry as a specialty and career choice.
Methods
Medical students in three Irish universities were invited via email to participate in an online survey to determine the frequency and effect of non-constructive criticism on choice of medical specialty. The online questionnaire was distributed to all medical students in three Irish medical schools (Royal College of Surgeons in Ireland (RCSI), University of Galway (UoG) and University College Dublin (UCD)) in the academic year 2020–2021. Students were informed that participation was voluntary. The survey invited undergraduate students from years 1–5, and Graduate Entry Medicine students years 1–4. Emails were sent through class and student society mailing lists inviting students to take part. Students received an initial invitation and two further reminder invitations. Responses were accepted for eight months in total and 146 valid responses were attained. Participants were assured that all responses were anonymous and that any identifying information would be stored and not distributed.
Questionnaire
The survey was created using Google forms and incorporated elements of previous surveys used (Ajaz 2016, Holmes 2008). We collected demographic detail including gender, age range, current year of study and university attended.
Respondents were asked to rank what medical specialties in their opinion receive the most non-constructive feedback, the major sources of these comments and the effect these comments may have on a student’s desire to pursue a career in psychiatry. Students were asked to note the frequency of non-constructive criticism heard from various academic and clinical staff and colleagues, including other medical students, administrative staff, non-consultant hospital doctors and consultants. Non-consultant hospital doctors were defined as doctors that are working as interns, SHO’s and Registrars. Tutors were clinical staff that are involved with lecturing students in their respective colleges, included were medical, surgical or those attached to a specific specialty. Specific specialties (Psychiatry, General Practice (GP), General Medicine, Surgery, Obstetrics and Gynaecology and Paediatrics) were selected to compare the degree of criticism observed for each, and from each level of medical staff, on a 5-point Likert scale (1 = none, 2 = infrequent, 3 = occasional, 4 = frequent and 5 = constant). Students were asked to measure on a 5-point Likert scale the likelihood that disparaging comments from medical staff would impact on their decision to pursue a career in psychiatry and if staff hierarchy affected this. This was measured using a 5-point Likert scale of strongly agree to strongly disagree (1 = Strongly agree, 2 = Agree, 3 = Neutral, 4 = Disagree, 5 = Strongly disagree). Additionally, focused statements relating to psychiatry were included in the questionnaire and answered on a similar 5-point Likert scale (e.g., ‘Psychiatry is not real medicine!’, ‘I would pursue psychiatry as a first-choice specialty’ and ‘I would agree with criticisms I have overheard regarding psychiatry’).
A blank text box was provided in which participants could provide examples of positive or negative comments that they had heard about psychiatry as a specialty.
Statistical analysis
Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) 27.0 for Windows (SPSS Inc., IBM, New York, USA). Descriptive analyses (frequencies, percentages, means and standard deviation) on key demographic and clinical data were performed for both categorical and continuous variables, as appropriate. We analysed the non-constructive criticism of specialties scale scores using a Mann-Whitney U test to provide mean ranks.
Free-text data were examined and were open-coded based on the framework of the questionnaire and on any other themes unrelated to these questions that emerged. This data attained from free texts was then grouped into themes pertaining to medical students’ perceptions of psychiatry by consensus of the researchers (NM, DVW & JL) (see Table 3).
Results
Study demographics
A total of 146 students, from three medical schools, completed the survey. The demographics of the participating students and their year of study are shown in Table 1.
Table 1. Demographics and non-constructive criticisms heard about specialties (n = 146)
UEM, Undergraduate entry medicine; GEM, graduate entry medicine.
From the nine specialties listed, students reported that they were most likely to hear criticism about general practice (69.0%), surgery (65.1) and psychiatry (50.4) (see Table 2). Seventeen students (11.6%) described not hearing any non-constructive criticism relating to the listed specialties.
Table 2. Frequency of negative comment categorised by clinical seniority and setting
Non-constructive criticism about given specialties
As can be seen in Table 3, negative comments were most frequently heard from other medical students (μ Rank = 3.49) and least frequently heard from academic university staff (μ Rank = 2.15). Surgery (n = 84, 57.5%), general practice (n = 89, 60.9%) and psychiatry (n = 65, 44.5%) were the specialties to which negative comments were most frequently directed on clinical placement.
Table 3. Comments heard about psychiatry
From the results we can see that medical students were the most likely to provide non-constructive criticisms with a mean rank of 3.49 with academic staff being least likely. During clinical rotations Surgery and General Practice were the most likely specialties for students to hear non-constructive criticism for, with a mean rank of 2.87, while psychiatry was given a rank of 2.62. With regard to psychiatry, medical students ranked highest on providing nonconstructive criticism with a mean rank of 2.99, while clinical tutors ranked lowest with a mean rank of 1.97.
Negative effects of non-constructive criticism on student consideration of a career in psychiatry (Fig. 1)
Comments made by non-consultant hospital doctors had the largest impact with n = 67 (45.9%) of respondents agreeing that it would impact their choice in choosing psychiatry, followed closely by consultants with n = 64 (43.8%) agreeing. Comments made by medical students had the least impact with only n = 43 (29.5%) agreeing.
Figure 1. Frequency of non-constructive criticism by clinical or academic roles.
Attitudes towards psychiatry as a speciality (Fig. 2)
In the response to the statement ‘Psychiatry is not real medicine’, the majority of students n = 138 (94.5%) disagreed. In response to the statement that ‘Psychiatry does not have a concrete scientific foundation’; n = 127 (87%) disagreed, n = 10 (6.9%) were neutral, while n = 8 (5.5%) agreed with the statement. On whether Psychiatry is a rapidly progressing field of medicine n = 15 (10.3%) disagreed, n = 35 (24%) were neutral on the statement, n = 96 (65.8%) agreed.
Figure 2. Frequency of student responses to negative statements regarding psychiatry as a specialty.
Attitudes to psychiatry as a career (Fig. 3)
Fifty nine percent (n = 86) disagreed with the statement ‘I would pursue psychiatry as a first-choice speciality’. Responders agreed n = 81 (58.2%) that they would feel supported by peers, colleagues and family in pursuing a career in psychiatry. Fifty percent (n = 73) agreed that ‘Flexibility in terms of work-life balance and models of practice is a key reason I would consider a career in psychiatry’. Most respondents, n = 59 (41%) were neutral on the statement: ‘recruitment efforts into psychiatry training programs are as prominent as any other medical field’.
Figure 3. Frequency of student responses to statements regarding psychiatry as a career.
We have included a table of free text comments made by those that responded to the survey. The students were asked to input specific comments heard about psychiatry. Comments noted were divided into separate themes with examples of each included in Table 3. Themes included both negative and positive comments made about psychiatry as a specialty as well as psychiatrists themselves, also comments made regarding psychiatry as a potential career choice. A full list of comments collected will be included in supplemental table 1.
Discussion
This is the first study that has been conducted in Ireland to assess the extent of badmouthing of medical specialties by doctors and academic tutors that medical students are exposed to during their undergraduate years. Students who participated attended three medical schools and included students across all medical years. Findings confirm that, as in other countries (Holmes et al. Reference Holmes, Tumiel-Berhalter, Zayas and Watkins2008; Ajaz et al. Reference Ajaz, David, Brown, Smuk and Korszun2016; Wainwright, et al. Reference Wainwright, Harris and Wainwright2019), there is a culture within the Irish medical community of criticising and badmouthing medical specialties.
Our study found that general practice, surgery and psychiatry, in that order, were the most frequently criticised specialties. This is consistent with a previous survey of medical students in the United Kingdom that reported psychiatry and general practice as the ‘most-bashed’ specialties (Ajaz et al. Reference Ajaz, David, Brown, Smuk and Korszun2016).
The badmouthing of specialties occurs soon after entering medical school, shown in our study by the fact that medical students were the group most frequently observed to be taking part in the bashing of specialties. However, caution is required with this interpretation, as medical students are in most contact with other medical students and thus the estimate of badmouthing of medical specialities by other groups may be an under-estimate, rather than medical students engaging in the most criticism. Non-consultant hospital doctors were more frequently heard badmouthing specialties than consultants, which may also be due to students having more contact with this group. While it is encouraging that academic tutors were the least likely to badmouth other specialties, it is hospital doctors who are medical students’ primary educators during clinical rotations.
An area of concern is the high proportion of students reporting that they would reconsider a career in psychiatry based on negative comments made about the specialty. While students were most likely to ‘agree’ that they would reconsider psychiatry because of critical comments made by consultants, it was badmouthing from non-consultant hospital doctors that had the most pronounced effect on medical students, with more students (46%) agreeing that they would reconsider a career in psychiatry based on comments from this group. This may be explained by medical students having more contact with and relating more easily to non-consultant hospital doctors. Regardless of seniority of medical staff, non-constructive criticism of specialties has implications for student interest in psychiatry as a career choice.
Our survey revealed a generally positive perception of psychiatry in Ireland as both a specialty and career choice. Twenty percent of students agreed with the statement ‘I would pursue psychiatry as a first choice career choice.’ This was higher than expected, considering the rate of medical students entering psychiatry has been consistently maintained at 4–5% in the UK and USA (Halder et al. Reference Halder, Hadjidemetriou, Pearson, Farooq, Lydall, Malik and Bhugra2013; Choudry & Farooq Reference Choudry and Farooq2017; Goldenberg, et al. Reference Goldenberg, Williams and Spollen2017). However, it was demonstrated in other studies that positive attitudes toward psychiatry often do not correlate with actual numbers entering the field (Warnke et al. Reference Warnke, Gamma, Buadze, Schleifer, Canela, Strebel, Tényi, Rössler, Rüsch and Liebrenz2018; Motlová et al. Reference Motlová, Janoušková, Formánek, Goetz, Holub, Hubeňák, Kašpárek, Látalová, Papežová, Světlák, Šilhán, Trančík, Vevera and Balon2020). Studies have also shown that the rate of students wishing to pursue psychiatry tends to decline as medical school progresses, despite perceptions of the specialty improving in this time (Warnke et al. Reference Warnke, Gamma, Buadze, Schleifer, Canela, Strebel, Tényi, Rössler, Rüsch and Liebrenz2018). This may in part be due to negative comments and their effect on career choice. Psychiatry and its patients have historically been stigmatised within wider society, a possible causative factor in psychiatry’s high rate of criticism. This may contribute to the negative effect of badmouthing on choosing psychiatry as a career (Qureshi et al. Reference Qureshi, Carney and Iversen2013; Choudry & Farooq Reference Choudry and Farooq2017; Motlová et al. Reference Motlová, Janoušková, Formánek, Goetz, Holub, Hubeňák, Kašpárek, Látalová, Papežová, Světlák, Šilhán, Trančík, Vevera and Balon2020). Introducing psychiatry modules earlier on in medical education, perhaps through a spiral curriculum, could improve perceptions earlier, combat stigmatisation and badmouthing and perhaps make psychiatry more attractive to students.
Multiple studies have referenced the perceived low status of psychiatry and general practice in the hierarchy of medical specialties (Eagles et al. Reference Eagles, Wilson, Murdoch and Brown2007; Pianosi et al. Reference Pianosi, Bethune and Hurley2016; Motlová et al. Reference Motlová, Janoušková, Formánek, Goetz, Holub, Hubeňák, Kašpárek, Látalová, Papežová, Světlák, Šilhán, Trančík, Vevera and Balon2020). Students have cited friends, tutors and families directly discouraging them from pursuing these specialties, with statements such as ‘[they should] have more ambition’ than pursuing general practice and that psychiatry ‘isn’t real medicine’ (Spooner et al. Reference Spooner, Pearson, Gibson and Checkland2017). The latter statement was quoted by multiple students in our study when asked to cite examples of critical comments they had heard about psychiatry, however, 95% reported that they disagreed with this.
Our study findings have implications for the delivery of medical education, demonstrating that in relation to medical students’ career choices, there is a significant amount of external influence in the form of badmouthing when it comes to psychiatry. Our findings also suggest that both surgery and general practice may be experiencing high levels of non-constructive criticisms, with both specialties receiving a higher mean rank at all levels excluding medical students. Another Irish study demonstrated similar findings for general practice (O Tuathail et al. Reference Tuathail, Mcnicholas and Synnott2021). General practice and psychiatry both face recruitment crises (Brown & Ryland Reference Brown and Ryland2019; O Tuathail et al. Reference Tuathail, Mcnicholas and Synnott2021), and as such we must be careful to avoid the propagation of non-constructive criticisms that have the potential to dissuade students from specific fields. Data from the US shows that interest in surgery is also decreasing (Peel et al. Reference Peel, Schlachta and Alkhamesi2018). In the UK, The Royal College of General Practitioners has called for primary and secondary care teams to work together to promote GP as a worthwhile specialty and not deter students from choosing this specialty (Rimmer, Reference Rimmer2017). Further research would be necessary to explore the effect of badmouthing on perceptions of and recruitment to surgery in Ireland.
It is important to consider why medical students’ career preferences, at least in relation to psychiatry as shown in our study, are so easily influenced by badmouthing done by clinical staff and why perceptions of prestige and status are so attractive, to the point where it affects their career choices. Many medical students express perfectionistic and competitive natures, with pressure from internal or external sources to excel, or may have been drawn to the prestige associated with medicine (Spooner et al. Reference Spooner, Pearson, Gibson and Checkland2017). It could be argued that these factors make medical students and doctors vulnerable to external influences when it comes to the important decision of choosing a specialty. However, further research would be required to assess this, and how it may be exacerbated by the effect of badmouthing. Some authors have suggested that efforts to build self-esteem and resilience among medical students could be a way to address the declining interest in criticised specialties (Rimmer Reference Rimmer2017; Brown & Ryland Reference Brown and Ryland2019).
Addressing this issue will require a significant and multi-faceted approach to promote a more positive view of psychiatry and to tackle the challenges of negative stereotypes. Several strategies may be required as part of this solution. Professionalism training may be required to provide an institutional response to the issue of badmouthing, negative attitudes and stigmatisation of specialties in healthcare (Holmes et al. Reference Holmes, Tumiel-Berhalter, Zayas and Watkins2008). This training would involve the education of both medical students and doctors, to inform about the negative impact of specialty-bashing and the creation of alternative narratives. Non-consultant hospital doctors and consultant specialists could be encouraged to stop exposing medical students to this, but success will require a significant cultural shift and promotion of collaborative and non-judgmental interspecialty working. Such developments might be included in wider initiatives to promote civility in healthcare (Maslach & Leiter Reference Maslach and Leiter2017; Dougherty & Perrone Reference Dougherty and Perrone2021).
In psychiatry, further efforts will be required to tackle the additional widespread stigma, which could be addressed by incorporating stigmatisation modules into psychiatry undergraduate education, and by promoting and encouraging student-led psychiatry societies, an intervention which has been successful internationally in helping promote a positive view of psychiatry in universities (Choudry & Farooq Reference Choudry and Farooq2017).
Strengths and limitations
There was a relatively small respondent sample in this survey, raising the possibility of selection bias in the study population. However, the proportion of students responding is comparable to that in the 2016 UK survey of 13 Medical Schools (Ajaz et al. Reference Ajaz, David, Brown, Smuk and Korszun2016). There was also a higher proportion of male respondents at 60%. Despite the relatively low number of responders, the study findings remain informative and are in keeping with similar surveys from other countries, suggesting that they are broadly reflective of experiences of badmouthing in the wider medical student population. Distributing the survey to three universities enhanced generalisability of our findings. Though it was not possible to confirm that the survey was distributed to all students in each university, we feel that the fact it was carried out as a multi-site survey ensures that the results will be less biased by individual institutions experiences. As such we were unable to accurately record the response rate. Medical students were found to be the most likely group to badmouth medical specialties, but this result may have been biased due to medical students having close contact with other medical students and are therefore more likely to hear critical views from this group. The figures for other cohorts of medical staff may therefore be an underestimate due to less time in their company. Due to the year the survey was carried out being in the height of the Covid-19 epidemic, criticisms heard may be under represented as students spent less time with their clinical teams, though great efforts were made by Universities to prevent this.
Conclusion
This study demonstrates that Irish medical students are exposed to high levels of criticism towards different medical specialties by all groups of clinicians, academics and students. This factor may contribute to recruitment crises in general practice and psychiatry, is potentially preventable, and intervention is possible to address it. Changing a systemic and ingrained culture is gradual. Starting with medical students and professionalism modules in medical education could be a way to create real and meaningful changes in how medical professionals talk to and about one another and help to build a genuine culture of civility. Preparing students for badmouthing, negative attitudes and stigmatisation in healthcare may help them to better recognise nonconstructive criticism of specialties. This may facilitate students making unbiased career choices, tackle recruitment issues, improve career satisfaction and patient outcomes.
Financial support
No financial support was provided for this study.
Competing interests
None of the authors present on this publication have declared a conflict of interest.
Ethical standard
Ethics approval was obtained from the Galway University Hospitals research ethics committee (Ref: C.A. 2436). The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
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