Non-psychiatric physicians’ learning experiences from past psychiatric training in Japan: a qualitative pilot study with intergroup contact theory approach

Abstract

Background

Stigma associated with mental illness remains a pervasive global issue. This stigma is particularly pronounced in Japan, where mental healthcare may be perceived as a distinct culture: separate from mainstream medical care. The present pilot study aimed to clarify the learning experiences derived from direct contact with psychiatric care settings as medical students and postgraduate residents among physicians who subsequently pursued specialties outside of psychiatry. We focused on how such training may contribute to reducing stigma and improving attitudes toward mental illness from the perspective of intergroup contact theory.

Methods

Semi-structured interviews were conducted with 10 physicians who had 3–5 years of experience in specialty training in a field other than psychiatry according to the specified interview guide. Participants were invited to reflect on their learning experiences in psychiatric training during their clinical clerkship in medical school and basic postgraduate clinical training. They were also asked to consider the application of these experiences in their current practice in their non-psychiatric specialty. Interview data were transcribed and analyzed using thematic analysis, with intergroup contact theory serving as the theoretical framework.

Results

Three themes emerged. 1) Exposure to inaccurate and biased information resulting in the formation of negative preconceptions toward mental illness. 2) Direct exposure to active psychiatric symptoms and process of addressing their negative preconceptions. 3) Acquisition and performance of tolerant attitude toward mental illness. There were optimal conditions of intergroup contact theory in the process of addressing participants’ preconceptions.

Conclusions

Psychiatric training may improve physicians’ attitudes toward mental illness and fosters interprofessional collaboration. Intergroup contact theory may offer a framework for understanding how structured interactions during training reduce stigma and promote more effective teamwork across medical specialties. Establishing an educational environment based on intergroup contact theory could contribute more to reducing learners’ stigma toward mental illness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08511-x.

Background

Stigma associated with mental health remains a pervasive issue globally and contributes to reduced access to healthcare and increased mortality rates [1–3]. Stigma toward various psychiatric diseases has been observed across various medical professions, and a range of interventions to improve stigma have been proposed and implemented worldwide [4]. Physicians’ stigmatizing attitude toward patients matters since that affects their patient centered care. Although epidemiological studies indicate that medical doctors generally exhibit less stigmatizing attitudes toward mental illness than the general public [5], stigma remains a salient issue in specific contexts. General practitioners who collaborated closely with mental health teams based in the same institution exhibited a reduced stigmatizing attitude [6]. However, medical students and postgraduate trainees were found to hold negative attitudes toward depression [7]. Another study reported that surgeons expressed a negative perception of patients who self-harmed [8]. Furthermore, a number of medical doctors exhibited less willingness to take on responsibility for psychiatric disease management as consultants, despite maintaining a positive attitude [9].

Such stigma is particularly pronounced in Japan, where societal attitudes toward mental illness tend to be more negative compared with those in other countries; this may discourage individuals who need psychiatric care from seeking these services [10–13]. Contributing factors include the overabundance of psychiatric beds (more than 300,000 beds in the whole country) and prolonged hospital stays in psychiatry (more than 250 days in mean length of hospital stay) in Japan, which create a perception of mental illness as a specialized problem [14]. Furthermore, psychiatric beds are largely confined to psychiatric hospitals, which are separate from general medical care facilities [15]. This means that medical students and healthcare professionals have limited opportunities to engage directly with patients with mental illness. Therefore, mental healthcare may be perceived as a psychologically distinct area within the healthcare system and separate from other areas of medical practice [16]. A low frequency of direct contact with patients with mental illness may be an important factor in the development of stigmatizing attitudes. For example, medical students and non-psychiatric doctors with a low frequency of exposure to cases of mental illness exhibited a higher degree of stigmatized attitudes toward mental illness compared with psychiatrists [17]. This tendency may be exacerbated in Japan, as patients with mental illness are often separated from general medical care facilities [14, 15].

Intergroup contact theory may serve as a theoretical framework and offer valuable lens to understand this issue [18]. This theory was originally proposed in response to racial prejudice. Prejudice is predominantly attributable to a dearth of knowledge concerning the other person and can be mitigated through enhanced opportunities for interaction with individuals from different backgrounds and exposure to authentic information. A previous systematic review demonstrated the effectiveness of intergroup contact theory in various contexts, with numerous studies supporting its impact in reducing prejudice across different social groups [19]. This theory has been applied to educational settings, such as in the jigsaw classroom [20]. It is also widely used in the field of medical education, especially in the context of cooperative learning and communication skills improvement [21]. Especially considering the ongoing challenging in Japan, intergroup contact theory could be a pivotal framework for problem resolution.

A potential strategy to mitigate this stigma is incorporating psychiatric education in medical training [22, 23]. Many countries have integrated psychiatry as a mandatory component in medical school curricula [24]. Therefore, it is critical to consider cultural and structural factors to effectively address and reduce stigma when designing psychiatric clinical training programs. The target trainees for such educational programs should include all medical students and postgraduate residents, the majority of whom will pursue specialties other than psychiatry [25]. It is important to understand what physicians in fields other than psychiatry gained from the education they received in psychiatry to inform development of such programs. However, there are few studies discussing stigma mitigating activities from the viewpoint of intergroup contact theory.

Intergroup contact theory is useful for understanding how psychiatric training could reduce stigma toward mental illness among medical professionals. Although psychiatric training may serve as a form of contact with a different cultural perspective for medical students and postgraduate residents, few studies have explored how learning experiences gained from such training among physicians who later specialized in non-psychiatric fields. The present pilot study aimed to clarify the learning experiences derived from direct contact with psychiatric care settings as medical students and postgraduate residents among physicians who subsequently pursued specialties outside of psychiatry. We focused on how such training may contribute to reducing stigma and improving attitudes toward mental illness from the perspective of intergroup contact theory.

Methods

We conducted a qualitative pilot study using semi-structured interviews about learning experiences in past psychiatric clinical training. Participants were recruited by purposive sampling, selecting individuals who met predefined inclusion criteria relevant to the study aims [26]. Physicians who had 3–5 years of experience in specialty training in a field other than psychiatry were included. Physicians who had a career in psychiatry were excluded. Participants were recruited through distribution regardless of region or hospital. The individual interviews were conducted either in person or online and lasted approximately 30 min. The interview guide is shown in Table 1. The interview guide did not ask directly about mental health related stigma in order to avoid social desirability bias affecting the response of participants. Participants were invited to reflect on their learning experiences in psychiatric training during their clinical clerkship in medical school and basic postgraduate clinical training. They were also asked to consider the application of these experiences in their current practice in their non-psychiatric specialty. Interview data were transcribed and analyzed using thematic analysis [27], with the process of coding, searching for themes, and reviewing themes. The extracted themes were interpreted with intergroup contact theory as the theoretical framework [18]. The analysis process involved repeated collaborative discussions among all authors of this study, including the expert of health professions education. When there were no new themes, categories, or insights emerging from interview data, the researchers shared the consensus that theoretical saturation was achieved [28].

Table 1.

Interview guide

I would like to ask you about the clinical clerkship in psychiatry that you completed when you were a medical student.
1	Before you started your clinical clerkship, what did you imagine it would be like?
2	Please tell me what your clinical clerkship was like.
3	Please tell me about a memorable experience you had during your clinical clerkship.
I would like to ask you about the postgraduate clinical training in psychiatry that you completed when you were a resident.
4	Before you started your postgraduate clinical training, what did you imagine it would be like?
5	How did you plan to use what you had learned about psychiatry up to that point in your training?
6	Please tell me what your postgraduate clinical training was like.
7	Please tell me about a memorable experience you had during your postgraduate clinical training.
I would like to ask you about your current medical treatment.
8	Please tell me how you feel your psychiatric clinical clerkship and postgraduate clinical training helped you in your current medical practice.
9	As you practice medicine now, what do you wish you had learned during your psychiatric clinical clerkship and postgraduate clinical training?
10	Please tell me about any components of the psychiatric clinical clerkship and postgraduate clinical training that you received that you feel are not useful in your current practice.

Participants received a written leaflet containing information about the study, and their written informed consent was obtained before the interviews. This study was approved by the Ethics Review Committees of Gifu University School of Medicine (approval number: 2023–279).

Results

Ten physicians participated in this study. One participant was female, and the remaining nine were male. The mean age was 30.7 ± 1.70 years. The mean number of years since completion of basic postgraduate clinical training was 3.7 ± 0.95 years. Participants’ specialty areas were general medicine (five participants), internal medicine (three participants; one each in neurology, cardiology, and hematology), emergency medicine (one participant), and orthopedics (one participant). The training period of undergraduate clinical clerkship in psychiatry were 1–2 weeks in nine participants and 4 weeks in one participant. The training period of postgraduate clinical training in psychiatry was 4 weeks for eight participants, 8 weeks for one participant, and no rotation for one participant (because psychiatry was elective until 2019). Nine participants undertook psychiatric clinical clerkship only in a university hospital, and one undertook it in both university and psychiatric hospitals. Six participants undertook postgraduate psychiatric training in a university hospital or general hospital, two undertook it in psychiatric hospital, and one undertook it in both general and psychiatric hospitals. Participants received psychiatric training in various settings including inpatient, outpatient, and consultation-liaison service.

Three themes were identified across three phases of training. 1) Exposure to inaccurate and biased information resulting in the formation of negative preconceptions toward mental illness: this emerged related to the phase before participants had received psychiatric training. 2) Direct exposure to active psychiatric symptoms and process of addressing their negative preconceptions: this reflected the psychiatric training phase. 3) Acquisition and performance of tolerant attitude toward mental illness: this captured the phase following the start of specialty training.

Theme 1: Exposure to inaccurate and biased information resulting in the formation of negative preconceptions toward mental illness

Participants had been exposed to societal stigma surrounding mental illness from an early stage in life. These fragmented, extreme, and stigmatized portrayals led to the development of the perception that psychiatric care was a dark, closed, and isolated field. The limited information available to medical students prevented them from forming a clear understanding of patients’ characteristics and the nature of psychiatry care.

When I was a child, there was a psychiatric hospital near where I lived. I was often told that if I behaved badly, I would be sent to the hospital. (Participant 3)

Perhaps I had the image of closed ward. I imagined it to be a dark place with lots of locked doors. (Participant 8)

Consequently, participants experienced feelings of anxiety and fear before they engaged directly with the field of psychiatry. Moreover, participants were informed by colleagues who had previously experienced clerkship in psychiatry about patients who made unusual sounds, exhibited incomprehensible behaviors, or attempted violent actions. This amplified their fears, with some even developing the impression that psychiatric patients were extremely abnormal.

I had some feelings of fear toward people with mental illness. (Participant 2)

Our classmates saw the patients acting strangely toward us. They behaved in a way that was impossible to understand. We heard some strange stories like this…I thought psychiatry was mysterious. Maybe that’s not the right word, but I thought of it like a zoo. (Participant 7)

In addition, participants had actually encountered patients with mental illnesses before their psychiatric training. They found it challenging to communicate with these patients and recognized they had insufficient skills in handling psychiatric issues.

Up until then, I had met many patients with mental illnesses, including those who had been taken to emergency room and those who were in hospital. While some of them were able to talk, there were also some who I couldn’t communicate with. (Participant 5)

I have seen patients who attempted suicide, and I didn’t know how to talk to them. (Participant 2)

Theme 2: Direct exposure to active psychiatric symptoms and process of addressing their negative preconceptions

Participants had direct contact with patients presenting severe psychiatric symptoms during their training. They were shocked by the intensity of the symptoms, and surprised by the invasive treatments required, but recognized the complexity of psychiatric care and the difficulty of treating such conditions.

I remember a patient from another country in the emergency room who seemed to have schizophrenia. At first, his symptoms didn’t change much, so I wondered if he might be depressed. But then he suddenly started raising his voice and got close to me…It was a shocking experience. I felt a little scared. (Participant 1)

One patient was so disruptive on the first day in the probation room that they had to be restrained. He was screaming, kicking and punching things, and completely naked. (Participant 2)

Some of the patients got violent, so I was a bit scared to walk down the hallway. (Participant 5)

I thought it would be hard for the patient to get better, that the patient’s family was really tired, and that even though we were trying lots of different things, it was difficult, and that it was hard to know how to act around the patient. (Participant 7)

Simultaneously, participants were also surprised by the experience of engaging in casual conversations with stable psychiatric patients whose symptoms were not immediately noticeable. This led to the understanding that even severe mental health conditions can improve and that patients in psychiatry did not fundamentally differ from patients in other medical specialties. As a result, participants exhibited an increased capacity for empathy and adopted a more holistic approach to treating patients with mental illness.

I had the chance to chat with a patient who was feeling down in a hallway for about an hour. It felt like we were talking in a friendly atmosphere. (Participant 7)

There are lots of medical records about his past state, but I thought he would just become a normal person. (Participant 9)

I got the impression that even though there may be times when I don’t understand the patient, that isn’t something to be afraid of. (Participant 10)

I had only seen the disease up until then, but it was a nice surprise to also see the human side of the person. (Participant 2)

In addition, participants saw multiple professionals in psychiatry working for improvement of patients’ symptoms and support of their daily life.

The patient opened up their feelings and current mental state, and the psychiatrist carefully interpreted them. (Participant 6)

I often talked with nurses, rehabilitation therapists, and dietitians. I felt that listening to opinions of various members could lead to better treatment. (Participant 7)

Theme 3: Acquisition and performance of tolerant attitude toward mental illness

Participants reported that their clinical training in psychiatry had provided them with an accurate understanding of mental illness, which helped reduce their prejudice and fear. This change in perspective enabled them to treat patients with coexisting mental illnesses with the same attitude as they would treat patients in their own specialty (i.e., non-psychiatric).

Since I have only experienced it once, I feel like the stress of not knowing what to do or being scared has reduced a bit. (Participant 1)

I realized that I could interact with this person calmly, as if they were no different from the people with physical illnesses that I deal with every day. (Participant 8)

In addition, participants indicated they grew more confident in independently managing a broad range of mental health issues. When encountering patients that required specialized psychiatric care, they were able to address the necessary steps within their own areas of expertise (e.g., physical assessments) before referring the patient for specialized care.

For example, if a patient has lost their appetite and we can’t find out why, we might use a scale such as the PHQ-9 to give them a score and try giving them a medicine such as mirtazapine. (Participant 6)

For example, if someone is depressed, I will often examine them closely to see if they have thyroid problems or other physical illness before sending them to a psychiatrist. (Participant 7)

Discussion

The present pilot study used a qualitative approach through the conceptual lens of intergroup contact theory to understand the educational influence of psychiatric training on physicians who subsequently pursued specialties other than psychiatry. The interrelationships among the extracted themes and their relationships with intergroup contact theory are shown in Fig. 1. This study revealed the development process of stigma toward mental illness among medical students and postgraduate residents and showed how this stigma was reduced by educational influence of psychiatric training. First, medical students and postgraduate residents were exposed to fragmented, extreme, and stigmatized information about mental illness, which led to the development of negative preconceptions. Second, direct interactions with patients with mental illness during training allowed participants to revise these preconceptions by providing an accurate understanding of mental health. Third, physicians were then able to effectively apply the knowledge and experience gained during their psychiatric training in their current specialty practice.

Fig. 1.

Medical students and postgraduate residents developed negative preconceptions before psychiatric training. Direct interaction with patients with mental illness during psychiatric training under the optimal conditions of intergroup contact theory allowed participants to revise their preconceptions by providing an accurate understanding of mental health. This recognition was maintained longitudinally in each participant’s current specialty practice

The focus in this study on changes in attitudes toward mental illness by having non-psychiatrists reflect on their experiences during their past psychiatric training was original. This viewpoint connects current activity of non-psychiatrists to their past learning experience in psychiatry. Many previous studies have focused on following either areas: psychiatric clinical clerkship for medical students or psychiatric education programs for non-psychiatrists [4]. Intergroup contact theory was suitable for explaining changes in perceptions and values that result from learning experiences.

Intergroup contact theory posits four optimal conditions that enhance the positive effects of intergroup contact: equal status between groups in the situation; common goals; intergroup cooperation; and support from authorities, law, or customs [19]. Participant 9 expressed that the patient without psychiatric symptoms was “a normal person”. This is the recognition of equal status between the participants and the patients. It is important for reducing stigma to know that many people with mental illness can live in their community [29]. Participant 2 noticed the human side of the patient other than the side of disease. This could be the experience of intergroup cooperation. Participant 6 watched the therapeutical interaction between patient and doctor, which is the work for remission and recovery as common goals. Participant 7 mentioned the collaboration with multidisciplinary staff. This situation, in which non-professional learners were surrounded by psychiatric professionals, constitutes support from authorities. If non-professional learners are exposed to active psychiatric symptoms alone, they might feel simply fear and develop negative preconceptions. On the contrary, optimal condition of intergroup contact theory might lead such learners to reduce stigma. These situations are universal among the clinical settings of psychiatry. However, these situations might not be familiar for healthcare workers other than psychiatry, including medical students and postgraduate residents. Establishing educational environment based on intergroup contact theory could contribute more to reducing learners’ stigma toward mental illness.

Current medical school teaching curriculum and basic postgraduate clinical training guidelines in Japan do not mention reducing stigma as an objective of psychiatric training. Participants in this study perceived the domain of mental healthcare as a psychologically distinct area and noted that developing a necessary relationship with this domain was among their significant learning needs. Reducing stigma reflects both learners’ and broader social needs, which should inform curriculum development [30]. Incorporation of anti-stigma training programs are desirable for meeting these needs [22, 23]. Properly integrating psychiatry throughout medical practice could be a psychiatric clinical training competency. Majority of medical students and postgraduate residents took psychiatric training in university and general hospitals. If the scale of psychiatric treatment at university hospitals and general hospitals increases and educational contents there improve, the effect of reducing stigma might be larger. However, psychiatric beds in general hospitals, including university hospitals, currently tend to decrease [15]. Developing educational strategy centered on psychiatric hospitals would be more realistic.

This study had several limitations. First, the number of participants was relatively small, and the distribution of sex and specialties exhibited some degree of bias. General practitioners were overrepresented, whereas surgeons, obstetricians/gynecologists, and pediatricians were absent. Although a certain degree of universal themes have been extracted, which is reasonable given this is a pilot study, further studies with larger and more diverse samples are necessary to address these limitations. However, the qualitative study design in itself is limited in terms of generalizing findings to a broader population. It is also necessary that the result of qualitative study may be affected by the background and experience of both researchers and participants. Second, member checking was not performed in this study, although it is often used in studies based on qualitative interviews to verify the accuracy of the transcribed data and extracted themes with participants. Member checking is a recognized method to enhance the credibility and trustworthiness of qualitative findings [31]. However, concerns were raised that member checking may introduce unnecessary misunderstandings to the interpretations in this study [32, 33]. Therefore, it was decided not to perform member checking based on consideration of the benefits and disadvantages. Third, recall and reconstruction bias could occur because participants were asked to remember their past experience in psychiatric training. Fourth, there could be sampling bias as we recruited participants who had expressed an interest in pursuing psychiatry when they were medical students or residents. Fifth, a comparison group could not be set because psychiatric clinical clerkship was mandatory in the Japanese medical school curriculum. However, selection bias might have occurred in that only participants realizing the significance of psychiatric training were recruited.

Conclusions

Psychiatric training may improve physicians’ attitudes toward mental illness and fosters interprofessional collaboration. Intergroup contact theory may offer a framework for understanding how structured interactions during training reduce stigma and promote more effective teamwork across medical specialties. Establishing educational environment based on intergroup contact theory could contribute more to reducing learners’ stigma toward mental illness.

Authors’ contributions

Y. M. conceptualized the study, collected data, conducted data analysis, and drafted the original manuscript. All authors drafted and revised the survey, revised the content of manuscript, and approved the final version for submission. C. K., O. M., and T. S. supervised the study at any process.

Funding

This study was supported by The Japan Society for the Promotion of Science (JSPS) KAKENHI (grant number 24K18740, Yusuke Matsuzaka).

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Review Committees of Gifu University School of Medicine. All methods were performed in accordance with the relevant guidelines and regulations. All participants were informed about this survey via a written leaflet. Responses to the questionnaire were anonymous. Participants’ consent was assumed if participants responded. Informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.