Perception of internal medicine residents regarding psychiatric patients’ care

Introduction: Mental disorders are accountable for the segregation of patients in many diverse cultures and historical moments worldwide. The evolution of neuroscience, technologies and advances in the psychosocial sphere have not been enough to change this paradigm. Many people still fear having social relations with someone with a psychiatric disorder, despite scientific progress and efforts to reduce prejudice in recent decades. Objective: The aim of this study was to assess the training in mental health during the undergraduate course offered to residents in Internal Medicine and analyze the feelings, perceptions, and stigmas of these physicians regarding the care offered to patients with mental disorders. Method: This study has a qualitative, quantitative approach and descriptive, cross-sectional design. Thirty-two residents in Internal Medicine participated and, for comparison, the questionnaires were also answered by 8 residents in Psychiatry. Two instruments were applied: one for the characterization of the participants’ sociodemographic profile and the attribution questionnaire (AQ-26B). Qualitative data were obtained through a focus group with 14 residents and the content analysis was used for categorization. The most frequent categories were illustrated with Pareto charts. Results: The results demonstrated that residents in internal medicine showed higher indexes of stigma regarding aspects such as fear and intolerance. It was also possible to infer gaps related to training in mental health, low perception of care responsibility, in addition to the difficulty in legitimizing complaints and showing negative feelings. Conclusion: One can conclude the need for educational interventions that promote the decrease of the stigma and the search for training regarding comprehensive and empathic care for patients with mental disorders.


INTRODUCTION
Traditionally, mental disorders are accountable for the segregation of patients in many diverse cultures and historical moments worldwide. The evolution of neuroscience, technologies and advances in the psychosocial sphere have not been enough to change this paradigm. Many people still fear having social relations with someone with a psychiatric disorder, despite scientific progress and efforts to reduce prejudice in recent decades [1][2][3] .
A psychiatric diagnosis is still associated with several factors -often referred to as stigma -that affect the patients' quality of life in the community and in therapeutic environments.
Health professionals are not immune to stigmas that affect these patients, resulting in a decrease in the search for care by a signification portion of this population and imposing obstacles to treatment, including in other medical areas such as medical clinic and specialties [1][2][3] . Thus, the experience resulting from having a psychological illness is added to a second dimension of suffering characterized by the social discredit associated with the disorder 4,5 .
Health care professionals may have negative attitudes when a psychiatric diagnosis is suspected 2,6 , with disastrous consequences for the user of a mental health service, such as delay in requesting help, greater social isolation and reduced possibility of functional return 4 .
Considering that the improvement of general practitioners' attitudes towards mental health and psychiatry may depend both on the curriculum and on the development of teaching and learning strategies, research aimed at improving students' contact with these areas should not be underestimated, as it may indicate possible interventions [7][8][9] .
The possible relationship between these perceptions and the training of general practitioners encouraged the choice of Internal Medicine residents as the object of study. Thus, this study aimed to analyze feelings, perceptions and stigmas among internal medicine residents when providing care to patients with mental disorders.

METHODS
This is an exploratory, cross-sectional study that used qualitative and quantitative approaches as shown below.  10 . AQ-26B comprises 26 questions addressing discomfort felt by the respondent regarding psychiatric patients in daily scenarios. It encompasses eight factors consisting of questions with scales ranging from 1 to 9, in which the higher the grade, the higher the discomfort. The final grade of each factor is the average of grades, i.e., the sum of scores divided by the number of questions in each dimension.
The scopes that comprise the questionnaire and the phrases that translate their meaning are 30 : • Fear: people with mental disorders cause fear because they are unpredictable and violent; • Help: people with mental disorders do not deserve help; • Segregation: people with mental disorders should be sent to institutions outside the community; • Avoidance: I do not want to live with people with mental disorders; • Pity: people with mental disorders are dominated by their disease, deserving concern and pity; • Anger: people with mental disorders are to blame for their disease and make other people angry; • Responsibility: people with mental disorders are able to control their symptoms and are responsible for their disease; • Coercion: people with mental disorders must undergo treatment. were: "How is it for you to provide care to someone with a mental disorder?" e "How do you see the training you received when you provide care to someone with a mental disorder?".
The study qualitative analysis was converted into categorical analysis based on the content analysis of Laurence Bardin 11 , with results that stood out from the others as illustrated by Pareto charts. Table 1 shows the sociodemographic data. Table 2 shows that Internal Medicine residents have significantly higher medians than Psychiatry residents in the attribution questionnaire regarding the factors fear and anger, i.e., when  compared to Psychiatry residents Internal Medicine ones expressed in their answers that people with mental disorders cause fear due to their unpredictability and aggressiveness, are to blame for their disease and make people around them angry.

RESULTS
The help, segregation, avoidance, pity, responsibility, and coercion factors showed similar scores between Internal Medicine residents and those in Psychiatry, with a significance level of 5%.
Most Internal Medicine residents declared they had participated in mental health care training during the undergraduate course (62.5%), but only 6.25% reported having had a similar experience during residency. Approximately 75% of residents claimed they had access to patients admitted to the psychiatric ward during their training in a general hospital.
In Table 3, it is noteworthy that differences between the years in internal medicine residency showed a significance level of 5% for the anger factor. Thus, it is estimated that first-year residents perceive patients as being to blame for their disease and responsible for causing anger in other people more than second-year ones.
The remaining factors and age showed similar results regardless of the residency year, i.e., they had a p-value > 0.05 in the tests. The highest mean values are related to coercion and avoidance, respectively the obligation to follow the treatment regardless of one's will and the lack of desire to live with patients that have mental disorders (Table 3). This conclusion is possible because, in a scale from 1 to 9, the means are considered high when they exceeded 4 among these factors.

Focus Group
While treating and interpreting the results, the exclusive categories created to decode both questions, after a critical, thoughtful analysis, aiming to unveil what "was not said" were:  This means that most participants reported doubting the accuracy of complaints by patients with mental disorders during the medical care. Those categories with accumulated percentage of less than 50% are considered the main ones appearing in the focus group. Therefore, although relevant, negative feelings, gaps in formation and care responsibility are reasons for less concern when designing action plans.
"How do you see the training you received when you provide care to someone with a mental disorder?" About the training received by the residents to provide care to patients, the category that prevailed was care responsibility (Pareto Chart 2).
Residents felt that, as mental disorders are considered complex conditions, such as bipolar disorder or schizophrenia, the professional actually responsible for treatment would be a psychiatrist. They claimed that, when providing care, interdisciplinarity should be prioritized with at least one psychologist per Basic Health Unit. Gaps in training and the legitimation of complaint appeared as secondary reasons, associated with the training the residents had in in medical school. The category negative feelings did not appear as a significant category regarding this question.

DISCUSSION
The data demonstrated that most Internal Medicine residents (75%) reported experiences with psychiatric patients in a general hospital and around 63% had mental health care training during undergraduate medical school.
Nevertheless, they showed higher stigma indexes related to factors such as fear and anger, attributing characteristics such as unpredictability and aggressiveness to the patients with mental disorders, as well as demonstrating higher degrees of anger and guilt due to their disorders when compared to psychiatry residents ( Outsourcing the care responsibility was even more significant in cases of mental disorders considered to be more severe, such as schizophrenia and bipolar affective disorder (Chart 2). This fact may be justified by the greater attribution of dangerous behaviors to these individuals, stimulating the desire for distancing and a greater level of skepticism regarding These findings suggest that the simple exposure to psychiatric patients and mental health contents of the undergraduate medical school curriculum may not satisfactorily contribute to reduce stigma and prejudice related to mental disorders 6 . The scientific literature shows discordant results, whether with an increase or decrease of prejudice after the completion of the psychiatry internship during the undergraduate medical course 6,12 . Probably, the relationship between teaching and the stigma is influenced by the quality of the curriculum taught, faculty attitudes and the health context in which these professionals are being trained 6,12 .
If, on the one hand, psychiatry in the medical curriculum contributes to the acquisition of new knowledge and the correction of preconceived concepts, more stereotyped attributions such as unpredictability, avoidance, possibility of violent acts and inability to cure have a lesser variability degree after having contact with mental health during undergraduate medical school. Therefore, the increase in knowledge is not automatically followed by the reduction in stigma and discrimination 13 . It was also observed that the higher the residency year, the lower the anger rate of students towards patients with mental disorders (Table 3), probably due to other variables not attributable only to the acquisition of technical knowledge.
Factors that precede the actual medical training may contribute to the construction of prejudice and prevent potential attitude changes that may be attained through training 6,14 . Among them, there are socioeconomic conditions, previous knowledge about mental health, familiarity with the provision of care to these patients, personal or family experience with psychiatric illness, attitudes from parents and the local culture and contact with this population 6 .
The aspects of stigma that showed the highest means in the attribution questionnaire among internal medicine residents were avoidance and coercion ( Topics related to mental health and psychiatry are approached superficially, sometimes outside the social and community context and with an eminently curative approach 19 . In certain cases, the training takes place in negative contexts, which contributes to reinforce stereotypes regarding psychiatric care, creating resistance that hinder the availability of general practitioners to provide care to patients with mental disorders 19   When assessing the results of the questions, it is noted that the gaps in training were not highlighted when analyzing the residents' answers to the questions related to their training and perceptions of care (Charts 1 e 2). This finding suggests that these gaps, although significant, do not surpass the low perception of the physician as responsible for care and the difficulty in legitimizing these patients' complaints. Thus, the need to find strategies to modify this reality is reinforced, seeking to optimize the professionals' ability to collect information about psychological suffering, beyond the approach focused on theoretical curriculum content.
Although the stigmas of medical professionals and students towards patients with mental disorders have been widely studied in the literature, strategies based on scientific evidence to reduce this stigma are still scarce 14 . It is a complex phenomenon to be understood, originated from social stereotypes previously acquired by students and which were not deconstructed during the training period or were even intensified during this period 13,26 . These stereotypes have consequences not only for psychiatric patients, but interfere in society as a whole 26 .
Although education about mental illnesses has the potential to reduce stigmas towards the patient, this decrease does not seem to have lasting consequences and tends to primarily influence people more likely to have contact with these individuals 5,26 . On the other hand, the relationship with members of a stigmatized group has been shown to be an effective way to reduce prejudice, causing changes in behavior and attitudes for a longer period 5,26 .
It is, therefore, urgent to foster curricular changes and strategies to facilitate the interaction of residents and medical students with psychiatric patients, resulting in greater familiarity with their demands. The mental health approach during medical training needs to promote communication skills, develop technical competence in assistance with the collection of qualified information, transform attitudes that provide empathic relationships, as well as foster the perception of the need for comprehensive patient care from the biopsychosocial and spiritual perspectives.

CONCLUSION
The collected data allowed us to conclude that Internal Medicine residents report gaps in training during the undergraduate course that make providing care to psychiatric patients difficult. However, these gaps are less important than the low perception of the physician as responsible for the care and the difficulty in legitimizing complaints of these individuals.
It is also noteworthy that internal medicine residents, despite having contact with psychiatric patients during the undergraduate course and residency, have higher rates of stigma than psychiatry residents, with emphasis on aspects such as fear and anger.
This study discloses the need for educational interventions that seek to train Internal Medicine students and residents to provide care to patients with mental disorders, providing a greater understanding of the need for