Motivations and Limitations of Pursuing a Career in Psychiatry: A Cross-Sectional Study from the United Arab Emirates

. Background . The global burden of mental disorders continues to grow with signi ﬁ cant health, social, and economic consequences. Unfortunately, the gap between the need for mental healthcare and its provision remains wide all over the world. The recruitment and retention of psychiatrists is a long-standing concern in the United Arab Emirates, with social stigma playing a potential role. This study is aimed at investigating the factors that a ﬀ ect psychiatrists ’ choice of psychiatry as an area of practice in the United Arab Emirates. Methods . This cross-sectional study was undertaken using an anonymized 30-item online questionnaire. Ethical approval was obtained from the United Arab Emirates University Social Sciences Research Ethics Committee prior to participant recruitment. We recruited quali ﬁ ed psychiatrists currently working in the United Arab Emirates. The structured questionnaire assessed the participants ’ sociodemographic factors and reasons for choosing psychiatry. Statistical analysis, including Pearson correlations and chi-square tests, was performed using the statistical package for the social sciences (SPSS) version 26. Results . We found that the doctors trained in the United Arab Emirates were statistically more likely to face opposition to specializing in psychiatry ( p value < 0.001). Participants with a family member or friend as a psychiatrist were more likely to choose psychiatry as a ﬁ rst-choice specialty ( p value 0.01). Psychiatrists below the age of 35 were more statistically likely to face opposition to their decision to specialize in psychiatry ( p value 0.006). Psychiatrists who regretted their decision to specialize in psychiatry were statistically more likely to feel this way in their ﬁ rst year of residency ( p value < 0.001). Conclusions . Multiple sociodemographic factors in ﬂ uence responses to the decision to specialize in psychiatry in the United Arab Emirates. Younger people and people who studied in or were a citizen of the United Arab Emirates were more likely to face opposition to their decision to specialize in psychiatry, indicating why there are such high rates of psychiatrists from overseas in the United Arab Emirates and shortages in the profession.


Background
The burden of mental health problems continues to rise across the globe, impacting healthcare delivery, health outcomes, and economies worldwide [1].Due to the increase in demand for mental health services, there is a need for well-resourced mental health services, evidence-based practice, and highly skilled and trained mental health professionals.
Health services are yet to respond adequately to the rising prevalence of mental health problems in populations and the burden of these disorders.The gap between the need for treatment or support and the provision of care is consequently wide across the globe [2,3].In low-and middleincome countries, between 76 and 85 percent of people with mental health problems receive no support or treatment [4].
Psychiatrists are integral to the mental health teams tasked with providing mental health support and treatment [5].Psychiatrists are clinically trained specialists who manage and treat people with a variety of mental health disorders, including mood disorders, psychotic disorders, and personality disorders.Psychiatrists work within multidisciplinary teams (MDT) in collaboration with other professionals within healthcare services [6].The recruitment and retention of psychiatrists is a longstanding concern within healthcare services [7,8].There have been warnings of a serious shortage of psychiatrists to cope with the mental health-related burden, limiting care provision to the vulnerable patient group with mental health problems [9].
Societal attitudes towards psychiatry as a subject and profession influence why individuals choose to work within this field and how they treat individuals with mental health disorders [10].Research in the field has identified various factors influencing a clinician's decision to pursue psychiatry [10][11][12][13].Research in this area would be particularly useful in the United Arab Emirates (UAE), as despite a rapid population growth, there are concerns that mental health services and care providers are not increasing at a rate consistent with the country's needs [13].
There have been calls to expand mental health services and research to cope with those needs [14,15].Despite a serious stigma attached to mental illness, mental health disorders are presently identified among the UAE's top five serious health problems, in addition to cardiovascular diseases, obesity, cancer, and diabetes [16,17].The latest publicly available government figures put the total number of psychiatrists in the country at 142, with 1.9 psychiatrists available per 100,000 individuals [18].The situation in the wider region is worse, with one psychiatrist available for 100,000 individuals [19].
This explains the paucity of mental health research and high-quality training programs, with long waiting lists for assessment and treatment of mental health disorders in the UAE [20].
Mental health services in the UAE rely heavily upon psychiatrists who are trained overseas [21].To train local psychiatrists, there is a psychiatry residency program in the UAE.The program consists of four years of supervised training following an internship.This residency program is delivered at accredited healthcare facilities across the UAE.This psychiatry residency program is competitive and requires medical students to pass through a rigorous, structured recruitment process [22].
The factors informing a clinician's decision to pursue psychiatry are varied and complex to predict [23].Previous studies have explored factors behind trainees' motivation to seek psychiatry as a career option, including the income of psychiatrists, the training programs, and the methods of teaching systems in medical schools.Nevertheless, other factors, such as the prognosis of psychiatric conditions, the stigma related to the specialty, and the emotional burden associated with this specialty, discouraged many trainees from pursuing a career in this field [23][24][25].
Currently, there is a lack of studies investigating the motivations for clinicians in the UAE choosing psychiatry as their specialist subject.This study will help identify target areas that require improvement to promote psychiatrist recruitment and retention levels in the UAE.A further aim of this study is to assess the differences in socio-demographic factors affecting psychiatrists' career decisions.These findings will help inform researchers of any generational or cultural differences in choosing psychiatry as a career [26].

Methods
2.1.Participants.The study sample was recruited through nonprobability convenience sampling and comprised 54 psychiatrists currently working in the UAE.The data collection was performed between October and December 2021.Study participants fulfilled the following eligibility criteria: (a) psychiatrists trained in, or are currently part of, the local UAE Psychiatry Residency Program and (b) psychiatrists currently working in the UAE who received their residency training outside the UAE.It was also within the inclusion criteria that participants had to provide consent to participate in the study.Clinicians completing a psychiatric placement as an intern or as part of another training program (e.g., family medicine) were not included in the study.This is an exploratory investigation, so no definitive calculation was made to determine the sample size.

Measures.
A survey method was utilized in this study, using an online questionnaire.A structured questionnaire with 30 items was used to measure sociodemographic variables and what factors affected the selection of psychiatry as a subject and profession (see Supplementary File (available here)).The questionnaire consisted of two sections: sociodemographic (15 questions) and psychiatry selection factors (15 questions).Responses were coded by giving them a numerical value.The questionnaire was reviewed by two experienced psychiatrists and pilot tested among five psychiatric residents in Al Ain Hospital to ensure the clarity and directness of the questions.Questions were then refined and rephrased according to the feedback.However, the questionnaire was not culturally validated and psychometric validity was not formally tested.
The questionnaire sought demographic data to assess differences in the factors which affected career decisions among participants.The questionnaire also measured the reasons participants chose psychiatry as a specialty and asked them to reflect on their decision to join psychiatry at the beginning of their professional journey.The online survey was designed and conducted in accordance with the criteria stated in the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [27].

Statistical Analysis.
Correlation analyses were used to identify the effect of sociodemographic factors on the choice of psychiatry as a specialty subject and area of practice for clinicians in the UAE and the reasons for this subject choice.Logistic regression analysis was employed to assess whether certain socioeconomic and personal factors predicted the choice of psychiatry as a field of specialization.Statistical analysis was performed using the statistical package for the social sciences (SPSS) version 26 and included Pearson correlations and chi-square tests.Nearly 30% of the participants rated their experience of psychiatry as a student as the most important factor behind their motivation to become a psychiatrist.65% decided to pursue psychiatry while going through their internship years.Table 2 shows the participants' views regarding the most important reasons behind their decision to train as a psychiatrist.
A majority of the respondents (68.5%) reported psychiatry as their first choice specialty at the time they decided about their training program, as shown in Figure 1.Among those who did not choose psychiatry as their first-choice career path, family medicine was the most popular first choice, followed by pediatrics and internal medicine.The majority of the respondents credited other doctors for introducing the concept of psychiatry as a career to them, with others stating factors like movies, books, and their personal experience of mental disorders, as depicted in Figure 2. The participants with psychiatrists among their family or friends were more likely to choose psychiatry as a first choice (p < 0:014).
UAE graduates were more likely to face opposition to their decision to specialize in psychiatry (p < 0:001).The authors used 35 years as the cutoff between the older and younger participants in the sample.According to estimates, the average age of students going to medical school is 20 years and it takes a minimum of 13 years to gain a consultant-level qualification [29,30].Younger psychiatrists, defined as those aged 35 and below, were statistically more likely to be reluctant to pursue psychiatry and face opposition to their decision to specialize in psychiatry (p < 0:006).Participants who were UAE nationals were more likely to face opposition to their decision to specialize in psychiatry (p < 0:014).Most respondents who faced opposition in choosing a career in psychiatry cited stigma as the main reason (58%), followed by family pressure in 35% of cases.
Nearly 19% of the respondents disclosed having experienced mental health problems in the past, while 26% identified themselves as having been in a carer role for someone with a mental illness.However, both variables did not reach statistical significance regarding the decision to choose psychiatry in this sample.55% of the participants who admitted regretting their decision at some point during their training did so during their first year of training, as depicted in Figure 3.These participants were statistically more likely to feel that way in their first year of residency (p < 0:001).
Overall, 85% of the psychiatrists who participated in our study reported that they would recommend a career in psychiatry to their family and friends.

Discussion
Individual perceptions of mental health problems and psychiatry as a profession are socially influenced.Career choice decisions are based on social comparisons, where peers' and seniors' perceptions of job choice are considered trustworthy, and positive role models seem to have an integral role in influencing trainees' decisions to choose psychiatry [31,32].In a 2019 study conducted in Saudi Arabia, the choice to select psychiatry was found to be influenced by several factors, with the availability of job positions and lifestyle being the most important motivating factors, while having a family member with a mental illness was deemed a deterrence [33].An earlier Iranian study confirmed the role stigmatization of psychiatry plays in discouraging medical students from considering psychiatry as a career [34].
Social influence may be especially notable in the UAE due to high levels of stigmatization of mental health prob-lems, likely to prevent people from choosing psychiatry as a specialty, reflected in the shortage of psychiatrists [16,17,20].In our sample, participants with a family member or friend as a psychiatrist were more likely to choose psychiatry as a first-choice specialty.This finding is consistent with the evidence in the literature [31,32,35].As opposition for a career role is experienced less in people with friends or family in the same or similar roles; understandably, psychiatrists with family or friends who are also psychiatrists would be more likely to choose psychiatry as their first choice specialist subject [36].
Our study found that UAE graduates and citizens were more likely to face opposition to their decision to specialize in psychiatry in comparison to non-UAE citizens and those who graduated overseas.This is again likely to be influenced by the stigmatization of mental health issues in the UAE, where the public generally holds negative attitudes toward people with mental health problems, which are then  Mental Illness internalized by people with mental health issues [37].Stigma is likely the primary influence in affecting career choices among psychiatrists.It is thought to affect their choice by decreasing their likelihood of having psychiatry as a longterm vocation.Specific experiences among medical students, such as being exposed to very unwell chronic patients with poor prognoses, may make them develop a more pessimistic view of psychiatry [38].At a personal level, there remains a concern among clinicians that disclosing mental illness could adversely impact their career prospects [39].In medical culture, help-seeking behavior can be perceived as a marker of weakness rather than empowerment [40].These concerns about the consequences of mental health disclosure are potential barriers to clinicians' mental health and professional well-being [39,40].Counterintuitively, stigma might create more passion and devotion rather than feelings of ambivalence that some may experience while considering psychiatry as a career path [35].This is expected with the growing interest in fighting stigma and increasing awareness about mental health worldwide among the general population [41].
Research has found that in the UAE, having close contact experience with people with mental health issues is related to a lower expression of stigmatization, whereas people with no previous contact were more likely to express higher levels of stigmatization [37].In our study, having a history of mental health problems or having a carer role was not found to be related to the decision to choose psychiatry among the participants.This could potentially have been due to the high proportion of participants who graduated and trained overseas [21].Thus, this sample may not have accurately reflected the general stigmatizing attitudes towards mental health issues within the UAE and may not be generalizable across UAE resident populations.
In our study, participants under 35 were more likely to be reluctant to choose psychiatry and face opposition to their decision to specialize in psychiatry compared to their older counterparts.Psychiatry has never had the popularity and glamour associated with specialties such as surgery or medicine.A young person contemplating a career in psychiatry is exposed to an image of a profession, especially in the popular culture, that is far from positive, with psychiatrists often appearing ineffective in managing their patients [42][43][44].The perception of psychiatry as an unscientific field affects the psychiatrists' authority negatively, and they seem relatively more marginalized than their medical colleagues in public debates about the profession and practice [45][46][47].Negative public perceptions, bolstered by the media, have contributed to the stigma associated with psychiatry and, indeed, those who choose to work as psychiatrists [48].Another potential explanation is the high proportion of older psychiatrists in this study belonging to a non-UAE background, thus not being exposed to the degree of stigma in their home countries at the time when they made their decision to pursue psychiatry.However, the future seems promising for young people studying and specializing in psychiatry, as focused training programs have been shown to positively affect mental health literacy and understanding [49,50].
Nearly a third of our respondents did not choose psychiatry as their first-choice career path (Figure 1), with family medicine being the most commonly pursued specialty among them.With mental health now recognized as fundamental to overall health and productivity throughout the lifespan, family physicians are expected to deal with many mental health disorders in the primary care setting [51,52].They share a similar holistic patient-centered approach to patient care as psychiatrists [53].Pediatrics was another popular choice in this group, most likely reflecting the developing interest in the interface between clinical pediatrics and child and adolescent mental health services [54].
The study participants who admitted that they regretted their decision to choose psychiatry were more likely to feel that way in the first year of training.This finding is consistent with the global recruitment and retention situation for 5 Mental Illness psychiatrists [55].Multiple factors influence the retention of psychiatrists in their early years of practice, including length and frequency of hours and conditions of work, personal assessment of their skills, and their experiences working in psychiatry [56].Aspiring psychiatrists may find it challenging in their early years to grasp the integrated nature of treating psychiatric conditions using pharmacological therapies in combination with psychosocial interventions.Young medical graduates are put off by the perceived disregard for the medical model in psychiatry and express antipathy to psychiatry due to their ambition to work in a specialty that is all about "curing" people [48].
Poor supervision during their training program, lack of improvement in the patient's condition, and the risks associated with the specialty, especially with possible aggressive and violent patients, create regrets and feelings of frustration that can turn into antipathy for psychiatry and affect clinicians' decision to continue in psychiatry [23,57].More work is needed to explore the effect of these obstacles on trainees in the UAE.
This study was not without limitations, including the generalizability of findings and the sociodemographic factors of participants.The small sample size and the use of convenience sampling reduce the generalizability of the results.There is a lack of research exploring this concept in the UAE, so it is unclear how pertinent these findings are cross-culturally.The sample included more female than male participants; most participants were of non-UAE nationality.Cultural differences could have influenced their decisions to study psychiatry.This does reflect the stigmatization of mental illness in the UAE and the lack of UAE nationals wanting to pursue a career in psychiatry.The stigma associated with mental health issues could have influenced participants' self-reports of their own mental health.Therefore, the self-reported methodology could have subjected findings to bias, including social desirability bias.Participants may not have been open about their past mental health issues for fear of judgment.Further research is required to study these reasons in detail, helping to improve the recruitment and retention of UAE psychiatrists in the future.

Conclusion
Multiple sociodemographic factors influence the decision to specialize in psychiatry in the UAE.Younger people and people who studied in or were a citizen of the United Arab Emirates were more likely to face opposition to their decision to specialize in psychiatry, indicating why there are such high rates of psychiatrists from overseas in the United Arab Emirates and shortages in the profession.These findings would help identify hurdles young Emirati clinicians face in choosing psychiatry, partly explaining the dearth of UAE-trained psychiatrists in the country.

Figure 1 :AFigure 2 :
Figure 1: Participants' first choice specialty at the time of joining the training program.N = 54.

Figure 3 :
Figure 3: Year of training during which participants regretted choosing psychiatry.N = 11.
2%) were above the age of 35 at the time of data collection, and 19 (71%) were non-Emiratis.Table 1 depicts the sociodemographic factors of the participant sample.

Table 1 :
Demographic characteristics of the participants.

Table 2 :
Participants' reasons for choosing psychiatry as a career.