Umadevi Vasudevan Senior Lecturer, Department of Psychiatry, Penang Medical College, Penang, Malaysia Arokiamary Bharathy Associate Professor, Department of Psychiatry, Penang Medical College, Penang, Malaysia Koay Jun Min Lecturer, Department of Pre-University Studies, Disted College, Penang, Malaysia Joseph Jacob Panikulam Senior Lecturer, Department of Psychiatry, Penang Medical College, Penang, Malaysia Fahad Saleem Senior Lecturer, Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
Azmi Hassali Head, Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
Vincent Russell Honorary Clinical Associate Professor, Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
Abstract Objective: We aimed to evaluate perceptions of a Royal College of Psychiatrists promotional film among Malaysian medical students. Methods: Year 3 (n=108) and Year 5 (n=108) students completed separate standard measures of attitudes to psychiatry: the ATP 30 and Balon scales, respectively. A questionnaire was also administered recording students’ sociodemographic information, career preferences, perceptions of the film’s effectiveness and its influence on career choice. Quantitative and qualitative analyses of responses were performed. Results: The overall response rate was 95.5%. Mean career preference ranking for psychiatry was higher for Year 5 than for Year 3 (p=0.025). For most Year 3 (64.8%) and Year 5 (58.3%) respondents the film conveyed a positive image of psychiatry. Fewer perceived it as influencing career choice: 31.4% for Year 3 and 27.2% for Year 5. Higher scores on both attitudinal scales correlated positively with increasing likelihood of students rating the film positively (Year 3: p=0.000; Year 5: p=0.003). Thematic content analysis suggested possible socio-cultural influences on students’ perceptions. Conclusions: Despite conveying a positive image of psychiatry, promotional films may have limited impact in changing students’ attitudes towards psychiatry and in increasing interest in psychiatry as a career. Keywords: medical students, attitudes, psychiatry, stigma and discrimination, transcultural psychiatry
he relatively small number of medical graduates pursuing psychiatry as a career is insufficient, in many countries, to meet the medical manpower needs of mental health services.1 This crisis in recruitment has prompted measures to encourage interest in the specialty. Among various initiatives, The Royal College of Psychiatrists, in 2013, commissioned a promotional film entitled A Different Life.2 The film portrayed the working life of the psychiatrist through a series of dramatised clinical scenarios. The film was disseminated on YouTube and a DVD was sent to RCPsych members, inviting them to show it to medical undergraduates when the opportunity arose.
There is an extensive literature exploring medical students’ attitudes to psychiatry and factors determining the choice of psychiatry as a career, but little regarding how medical students themselves perceive recruitment initiatives.3 One study explored the impact of a promotional DVD, released in 2008 by The Royal Australian
Corresponding author: Professor Vincent Russell, Clinical Director, Cavan-Monaghan Mental Health Service, Drumalee Primary Care Building, Drumalee, Cavan, Ireland. Email: [email protected]
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and New Zealand College of Psychiatrists. It concluded that the film was effective in improving medical students’ attitudes to psychiatry and in increasing interest in the specialty, but the response rate was low.4 There are significant costs associated with the production and dissemination of promotional films. It is important, therefore, that such measures are evaluated, especially from the perspective of the target group. Against this background, the aim of our study was to determine perceptions of the film A Different Life among students at Penang Medical College (PMC), Malaysia.
Methods PMC is jointly owned and operated by the Royal College of Surgeons in Ireland and University College Dublin, Ireland. Students spend the first 2 years in Dublin, after which they return to Penang for their clinical training which includes an 8-week posting in psychiatry. All Year 3 (n=111) and Year 5 (n=113) students were invited to participate. Year 5 students had completed the psychiatry clerkship, while Year 3 had not. Prior to viewing the film, Year 3 students completed the 30-item Attitudes to Psychiatry questionnaire (ATP 30), which is scored on a 5-point Likert scale with higher scores indicating more positive attitudes.5 Year 5 students completed the 29-item questionnaire, developed by Balon et al. (1999), which is modified for respondents who have completed a clinical posting in psychiatry and which uses a 4-point Likert scale.6 Both years also completed a two-part questionnaire, developed by the authors. Part 1 sought demographic information, career preferences and opinions on various factors influencing career choices. Part 2, completed after viewing the film, contained a series of closed and open questions rating the film’s effectiveness across several domains on a 3-point scale (effective, fairly effective, poorly effective) and exploring what they liked most and least about the film. The study was carried out on a date and time agreed through the class representatives. Ethical approval was obtained from the Joint Penang Ethics Committee. The Statistical Package for Social Sciences (Version 18) was used for quantitative data analysis. Spearman’s rho analysis was employed to determine correlations between students’ ATP and Balon scores and perceived effectiveness of the film. Responses to open questions were transcribed verbatim and read separately by the authors to identify emerging themes. Areas of divergence were subsequently discussed among all co-investigators and consensus was achieved on a final set of themes.
21–24 years (99%). Ethnic background was predominantly Malay (62.9%), followed by Chinese (27%) and Indian (7.4%). Psychiatry was ranked sixth of seven specialties in terms of career preference for both Year 3 and Year 5 students. The mean career preference ranking for psychiatry (p=0.025) was significantly higher for Year 5 than for Year 3 students. Seventy (64.8%) and 63 (58.3%) respondents, from Year 3 and Year 5, respectively, rated the film as “effective” in “conveying a positive image of psychiatry” (Table 1). A minority in both years rated the film as “effective” in “increasing interest in psychiatry as a career” (31.4% and 27.2% for Years 3 and 5, respectively) while 71.2% of Year 3 and 69.4% of Year 5 respondents rated the movie as “culturally appropriate”. There were no significant correlations between perceived effectiveness of the film and age or gender. Ethnicity was strongly associated with perceived effectiveness of the film. Malay students in both years were more likely than non-Malays to report that the film presented a “realistic picture of psychiatry” (p=0.007), “increased interest in psychiatry as a career” (p=0.047) and “increased understanding of the role of a psychiatrist” (p=0.01). The mean total ATP and Balon scale scores for Year 3 and Year 5 were 102.44 (SD: 10.55) and 89.33 (SD: 7.79), respectively. Further analysis revealed a positive correlation between the scores on both scales and likelihood of respondents perceiving that the movie was effective (Year 3: rs (107)=0.392, p=0.000; Year 5: rs (108)=0.282, p=0.003). A positive correlation was also found between ATP scores and likelihood of choosing psychiatry as a career for Year 3 (p=0.03). For Year 5, using the Balon scale, this was non-significant.
What students liked most about the film Thematic analysis of responses of Year 3 students to this question suggested that the film portrayed psychiatrist– patient interactions positively and conveyed a hopeful message. There were several references to qualities of empathy and compassion that the film illustrated, and to the positive impact of psychiatry on the patients’ lives. The patients eventually put on a smile – they recovered The psychiatrist showed a lot of effort to understand the woman Among Year 5 students, the predominant themes that emerged in response to the same question were that the film presented a realistic picture and emphasised the importance of the bio-psychosocial approach.
Quantitative findings The response was 108 students from Year 3 and 108 from Year 5 (95.5% overall). Most students in both classes were single (95.8%), female (59.2%) and aged
The way the female doctor persuaded the patient to go for talk therapy
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Table 1. Perceived effectiveness of the film: Years 3 and 5 Effective (%) Presented a realistic picture of psychiatry Year 3 56 (51.8) Year 5 58 (53.7) Increased your interest in psychiatry as a career Year 3 34 (31.4) Year 5 30 (27.2) Increased your understanding of the role of a psychiatrist Year 3 63 (58.3) Year 5 59 (54.6) Succeeded in conveying a positive message about psychiatry Year 3 70 (64.8) Year 5 63 (58.3) Was culturally appropriate Year 3 77 (71.2) Year 5 75 (69.4)
The doctor reminding the medical student to treat the patient, not just the disease A sub-theme among responses from both years was a positive perception of the film’s technical aspects and production quality, particularly the sound effects and atmosphere created. The tone of mystery in the sound track made me anticipate a more dramatic role than I would expect from a psychiatrist
What students liked least about the film A predominant theme in Year 3 responses to this question was that the film portrayed an unrealistic picture of psychiatry in that too few of the negative aspects were shown, especially the extent to which patients could be violent. Failing to show possible bad outcomes The patients were too timid In reality the doctor may encounter some patients who are violent A further criticism was that the film provided too little information about the life and career of a psychiatrist. Not enough information about the career It didn’t really show the downside of psychiatry – how it affects the psychiatrist’s life
Fairly effective (%)
Poorly effective (%)
42 (39.3) 38 (35.2)
10 (9.2) 12 (11.1)
45 (42.1) 42 (38.9)
29 (26.8) 36 (33.3)
32 (29.9) 35 (32.4)
13 (12.0) 14 (12.9)
25 (23.4) 31 (28.7)
13 (12.0) 14 (12.9)
20 (18.7) 20 (18.5)
11 (10.1) 13 (12.0)
Year 5 students’ responses were generally less critical of the film. However, they frequently reported that the film did not improve on the understanding of psychiatry acquired during their posting.
Discussion Our findings suggest that A Different Life made a generally favourable impression. Students in both years were engaged by the film’s technical aspects and by the empathy demonstrated by psychiatrists towards patients in the dramatised vignettes. Responses to the questionnaire’s open questions suggest that the film also succeeded in communicating that psychiatry values holistic approaches and talking therapies. Scores from Year 3 and Year 5 regarding attitudes to psychiatry do not allow for direct comparison as the scales used were not identical. However, there was a significant positive correlation between students’ scores on both the ATP-30 and Balon scale, determined before viewing the film, and the likelihood of them perceiving the film as effective. This suggests that, for both Years 3 and 5, the film was better received by those whose pre-existing attitudes to psychiatry were positive. Consequently, we found no evidence that the film actually changed students’ attitudes. It is of some concern that Year 3 students, despite having had no prior clinical experience in psychiatry, frequently commented that the film underestimated the potential for violence and portrayed patients as “too timid”. This suggests that Year 3 students may have been relatively more influenced by prevailing negative societal stereotypes of people with mental illness.7
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Studies have suggested that undergraduate teaching programmes exert a relatively powerful influence on students’ attitudes towards psychiatry that is mostly positive.3 Our findings that a higher proportion of Year 5 students identified psychiatry as a “likely” or “chosen” career are consistent in this respect, as was the finding that, for Year 5 students, the film did not add to their understanding. In low and middle-income countries, recruitment into psychiatry remains very limited, while mental health services in developed countries continue to rely heavily on foreign medical graduates.1 In this context, it is reassuring that the majority of our respondents rated the film highly in the area of cultural appropriateness. The finding that ethnic Malay students were more likely than non-Malays to view the film as culturally appropriate may be interpreted in a socio-cultural context.8 The relative proportion of respondents from the three main ethnic groups in our study reflects the demography of Malaysia as a whole. The film portrayed a Muslim woman, apparently from a war-torn region, presenting with post-traumatic symptoms, who was responded to with warmth and understanding by a young psychiatrist. Malay students, all of them Muslim, may have reacted relatively more positively to this poignant vignette, illustrating the extent to which ethnocultural characteristics of the viewership may influence global perceptions. That the film was not perceived by the majority of students as influencing their choice of career is consistent with results from the previous Australian study.4 Open question responses, moreover, suggested that the film did not sufficiently address relevant issues such as the career path and psychiatrists’ emotional reactions to their job, and as such, may not have met the expectations created by its title.
Conclusion While A Different Life was perceived as conveying a positive image of psychiatry and as culturally appropriate, our findings suggest that it may not have been effective in changing attitudes of medical students who were not already positively disposed towards psychiatry. Further research is needed to establish whether promotional films are cost-effective in comparison with initiatives designed to increase positive experiences during undergraduate clinical postings or recruitment strategies which offer direct contact with psychiatrists and their working lives. Acknowledgements The authors wish to thank the students and staff of Penang Medical College.
Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Lyons Z. Attitudes of medical students toward psychiatry and psychiatry as a career: A systematic review. Acad Psychiatry 2013; 37: 150–157. 2. Ahmed K. A Different Life. Available at: http://www.youtube.com/watch?v=EB2opEiykg. Royal College of Psychiatrists, 2013. 3. Korszun A, Dinos S, Ahmed K, et al. Medical student attitudes about mental illness: Does medical-school education reduce stigma? Acad Psychiatry 2012; 36: 197–204. 4. Robertson T, Walter G, Soh N, et al. Medical student attitudes towards a career in psychiatry before and after viewing a promotional DVD. Australas Psychiatry 2009; 17: 311–317. 5. Burra P, Kalin R, Leichner P, et al. The ATP 30- A scale for measuring medical students’ attitudes to psychiatry. Med Educ 1982; 16: 31–38. 6. Balon R, Franchini G, Freeman P, et al. Medical students’ attitudes and views of psychiatry. Acad Psychiatry 1999; 23: 30–36. 7. Yeap R and Low W. Mental health knowledge, attitude and help-seeking tendency: A Malaysian context. Singapore Med J 2009; 50: 1169–1176. 8. Bharathy A, Malayapillay R and Russell V. Crosscultural narratives on death and bereavement among medical students: Implications for undergraduate curricula. Int J Med Educ 2013; 4: 68–74.
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