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Research Training in Psychiatry Residency: Strategies for Reform RESEARCH TRAINING IN PSYCHIATRY RESIDENCY STRATEGIES FOR REFORM Committee on Incorporating Research into Psychiatry Residency Training Board on Neuroscience and Behavioral Health Michael T. Abrams, Kathleen M. Patchan, and Thomas F. Boat, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu
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Research Training in Psychiatry Residency: Strategies for Reform THE NATIONAL ACADEMIES PRESS 500 Fifth STREET, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Institute of Mental Health. The views presented in this report are those of the Institute of Medicine Committee on Incorporating Research into Psychiatry Residency Training and are not necessarily those of the funding agencies. International Standard Book Number 0-309-09071-7 International Standard Book Number 0-309-52741-4 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover art: “The Thinker” by Brian S. McQuillan
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Research Training in Psychiatry Residency: Strategies for Reform “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health
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Research Training in Psychiatry Residency: Strategies for Reform THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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Research Training in Psychiatry Residency: Strategies for Reform COMMITTEE ON INCORPORATING RESEARCH INTO PSYCHIATRY RESIDENCY TRAINING THOMAS F. BOAT (Chair), Chairman, Department of Pediatrics, Unversity of Cincinnati, Ohio BARBARA F. ATKINSON, Dean, School of Medicine, University of Kansas, Kansas City BENJAMIN S. BUNNEY, Charles BG Murphy Professor and Chairman, Department of Psychiatry, Yale University, New Haven, Connecticut GABRIELLE A. CARLSON, Director, Child Psychiatry, State University of New York at Stony Brook, New York JAMES J. HUDZIAK, Director, Child Psychiatry, University of Vermont, Burlington DEAN G. KILPATRICK, Professor, Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston WILLIAM B. LAWSON, Professor and Chair of Psychiatry, Howard University, Washington, D.C. VIRGINIA MAN-YEE LEE, Co-Director, Center of Neurodegenerative Disease Research, University of Pennsylvania, Philadelphia JEROME B. POSNER, George Cotzias Chair, Neuro-Oncology, Memorial Sloan-Kettering Cancer Center, New York MICHELLE B. RIBA, Associate Chair, Department of Psychiatry, University of Michigan Medical Center, Ann Arbor RICHARD M. SCHEFFLER, Professor, School of Public Health, University of California, Berkeley JOEL YAGER, Professor and Vice Chair for Education, University of New Mexico, Albuquerque Board on Neuroscience and Behavioral Health Liaison DAVID REISS, Professor, Psychiatry, George Washington University, Washington, D.C.
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Research Training in Psychiatry Residency: Strategies for Reform Study Staff MICHAEL T. ABRAMS, Study Director KATHLEEN M. PATCHAN, Research Assistant (from October 2002) MILAP NOWRANGI, Research Assistant (January-July 2002) BRIAN S. McQUILLAN, Senior Project Assistant (December 2001-October 2002) PARISA MORRIS, Christine Mirzayan Intern (June-August 2002) Board on Neuroscience and Behavioral Health Staff ANDREW M. POPE, Acting Director TERRY C. PELLMAR, Director (until October 2002) JANET JOY, Senior Program Officer MICHAEL T. ABRAMS, Program Officer LAUREN HONESS-MORREALE, Program Officer LYNN NIELSEN-BOHLMAN, Program Officer PATRICIA CUFF, Research Associate ALLISON M. PANZER, Research Assistant KATHLEEN M. PATCHAN, Research Assistant LORA K. TAYLOR, Senior Project Assistant ALLISON BERGER, Project Assistant ROSA POMMIER, Finance Officer
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Research Training in Psychiatry Residency: Strategies for Reform INDEPENDENT REPORT REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Joseph D. Bloom, Oregon Health Services University, School of Medicine Veronica M. Catanese, New York University School of Medicine Mina K. Dulcan, Northwestern University, Feinberg School of Medicine Larry D. Gruppen, University of Michigan Medical School Lewis L. Judd, University of California, San Diego School of Medicine Jeffrey A. Lieberman, University of North Carolina School of Medicine Georgine M. Pion, Vanderbilt Institute for Public Policy Studies Ronald O. Rieder, Columbia University, and New York State Psychiatric Institute Stephen C. Scheiber, American Board of Psychiatry and Neurology Charles B. Wilson, Health Technology Center, and the University of California, San Francisco Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David N. Sundwall, American Clinical Laboratory Association, and Henry W. Riecken, University of Pennsylvania. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Research Training in Psychiatry Residency: Strategies for Reform Preface Large numbers of individuals are in need of treatment and support for mental disorders. At the same time, the capacity of the health care system to support caregivers and other resources has lagged behind the demand for services. Over the decades, outcomes for individuals with serious behavioral problems have improved, but much needs to be done to meet current needs. Strategic initiatives to meet this challenge include improving care systems, as well as improving modalities of care—diagnostic, therapeutic, and preventive. Ultimately, new modalities of care will be required to ensure a more effective and efficient mental health care system. Opportunities for improvement through research have never been greater. Research tools, both biological and clinical, are increasingly applicable to a wide range of mental health questions and problems. Rapid advances in understanding the biological and functional basis for behavior and its alterations promise to spawn creative and effective clinical insights. The National Institute of Mental Health sponsored this study of research training in psychiatry residency because of a growing concern that the numbers of psychiatrist-investigators have been falling short of meeting the need and the opportunities to advance the field. This concern is particularly acute in the area of child and adolescent psychiatry. NIMH, while certainly eager to stimulate relevant efforts in biological discovery, was particularly eager to focus this study on efforts directed at training of patient-oriented investigators. The study committee, convened by the Institute of Medicine at the request of NIMH, gathered relevant information from many sources, but soon recognized that evidence available for assessing the magnitude of perceived problems in psychiatric research training and for devising potential solutions is limited. In addition, the committee’s assessment was
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Research Training in Psychiatry Residency: Strategies for Reform complicated by several factors: (1) much psychiatric research is carried out by Ph.D. scientists as well as by psychiatrist-investigators; (2) psychiatry is less uniformly oriented to standard treatment approaches than are other specialties; and (3) the charge to the committee was to focus on research in core residency training, a segment of training that has traditionally had the objective of ensuring clinical rather than research competency. Recognizing the challenge inherent in its assignment, the committee resolutely considered a broad range of salient information in formulating a set of recommendations that reflect current evidence, as well as numerous carefully considered opinions. Among its recommendations, the committee in particular calls for a more cohesive approach by the psychiatry community to the issue of research training of psychiatrists, which as a first step would include assembly of a broadly representative national body to implement and further craft strategies to ensure more successful recruitment and training of psychiatrists for productive research careers. Thus, the committee hopes its efforts will be taken up by a steering group empowered to monitor and make future improvements to the training of psychiatrist-investigators as needed to advance psychiatric practice. I would like to thank all the members of the committee for spirited discussions tempered by a sense of purpose, including a uniformly perceived need to present a call for action. I am certain that all the members join me in expressing deep appreciation to Michael Abrams, whose insights, determination, and persistence were key factors in translating a large volume of information and opinions into a cohesive report. Finally, I wish to acknowledge the contribution of a few individuals who offered “behind the scenes” assistance to the completion of this report. Manuscript review and senior-level project support were furnished by Gooloo Wunderlich, Andy Pope, Melvin Worth, Douglas Weil, and Terry Pellmar. Detailed editing of the full report was provided by Rona Briere, while Margie Patlak provided some useful science writing. Finally, Sharon Turner and Judy Estep both offered important meeting planning and production support in the late stages of the study. Other contributors to this study are acknowledged throughout the text or listed in appendix A. In short, this report could not have been completed without the generous cooperation of a great number of competent individuals. Thomas F. Boat Chair
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Research Training in Psychiatry Residency: Strategies for Reform Contents Executive Summary 1 1 Introduction 21 Study Context, 21 The Burden of Mental Illness, 21 Increasing Societal Awareness of Mental Illness, 22 Advances in Mental Health Care, 22 Genesis of the Study, 25 Trends in Training of Psychiatrist-Researchers, 25 Study Charge, 29 Composition of the Committee, 30 Study Approach and Scope, 30 Overall Strategy, 30 Definitions and Broad Concepts, 30 Limitations of the Data, 34 Organization of the Report, 34 2 Residency as Part of a Longitudinal Career Continuum 37 Residency as an Important Target for Research Training, 37 Research Literacy, 39 Exposures and Experiences, 40 Opportunities to Formulate Patient-Oriented Research Questions, 42 Attracting and Sustaining the Interest of Talented Medical Students, 42 Importance of Longitudinal Training for Potential Researchers, 43 Preresidency Experiences, 44 Postresidency Experiences, 47 Strategic Considerations, 54 Models from Outside of Psychiatry, 55 Conclusions and Recommendation 2.1, 58
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Research Training in Psychiatry Residency: Strategies for Reform 3 Regulatory Factors 61 Psychiatry Residency Review Committee, 61 Organization and Function, 61 A Brief Detour into Psychodynamic Psychotherapy, 64 Clinical Requirements for Psychiatry Training, 68 Other Opportunities for Research Experiences in Residency, 75 Research Requirements for Psychiatric Residency, 77 Certification Board, American Board of Psychiatry and Neurology, 80 American Medical Association, 82 Other National Organizations Involved in Psychiatric Research Training, 82 American Psychiatric Association, 82 American Academy of Child and Adolescent Psychiatry, 83 Other National Organizations, 84 Conclusions and Recommendations, 84 4 Institutional Factors 91 Funding Issues in Graduate Medical Education, 91 The General Funding Stream, 91 Funding Issues in Pediatric Graduate Medical Education, 93 Supporting Research Activity Through Graduate Medical Education Funds, 93 General Research Funding, 95 Leadership and Mentoring, 102 Institutional Leadership, 102 Departmental Leadership, 104 Mentorship, 105 Program and Curriculum Structure, 109 Published Reports on Research Curriculum Design, 109 Illustrative Programs, 114 Other Aggregate Program Data, 120 Conclusions and Recommendations, 125 5 Personal Factors 133 Innate Characteristics, 133 Motivation and Drive, 134 Intellectual Capacity and Scientific Orientation, 134 Personal Financial Concerns, 138 Student Debt, 138 Residency and Fellowship Stipends, 139
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Research Training in Psychiatry Residency: Strategies for Reform Salaries of Psychiatrists Compared with Other Specialties, 139 Salary Differences Between Clinicians and Researchers, 141 Nonsalary Benefits of a Research Career, 144 Representation of Women, International Medical Graduates, and Racial Minorities in Psychiatry, 150 Women, 152 International Medical Graduates, 154 Underrepresented Racial and Ethnic Minorities, 156 Conclusions and Recommendations, 159 6 Future Directions for Promoting the Development of Psychiatrist-Researchers 167 Workforce Estimates and Monitoring, 167 Outcome Data in Research Training, 171 National Coordinating Effort, 173 Overarching Recommendation, 174 References 177 Appendix A: Data Sources and Methods 201 Appendix B: Federal and Other Funding Mechanisms Listed and Summarized by Career Stage 211 Appendix C: Brief Descriptions of Psychiatry Residency Training Programs 231 Appendix D: Committee and Staff Biographies 247
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Research Training in Psychiatry Residency: Strategies for Reform Tables, Figures, and Boxes TABLES ES-1 Summary of Recommendations, 19 1-1 Research Involvement Rates of Practicing Psychiatrists, 27 2-1 Western Psychiatric Institute and Clinic’s Developmental Pathways for Psychiatric Researchers, 55 2-2 Duration in Years of the Two Stages of Pediatric Subspecialty Training Pathways, 57 3-1 Summary of Duration, Time, and Research Requirements for Accredited Residency Training Programs, 70–71 4-1 Sources of Graduate Medical Education Funding, 92 4-2 Research Training Outcome Data from Several Residency Programs in Psychiatry, 124 4-3 Continuum of Residency-Based Research Training, 131 5-1 Examination Scores by Specialty Choice upon Entry to Medical School (MCAT) and upon Entry to Residency (USMLE), 136 5-2 Median Expected Starting Income for Graduates of New York State and California Residency Training Programs, 2002, 140 5-3 Selected Data from the American Psychiatric Association’s 1998 National Survey of Psychiatric Practice, 143 5-4 Demographic Composition of Residents in Various Specialties or Subspecialties of Medicine, 151 FIGURES 1-1 Percent of National Institute of Mental Health (NIMH) extramural grants stratified by the five major disciplines, 26 2-1 Training pathways in psychiatry, 38
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Research Training in Psychiatry Residency: Strategies for Reform 5-1 Ratio of demand to supply of medical students who designate a given residency as their first career choice, versus the expected lifetime income, 141 5-2 Percent of National Institute of Mental Health (NIMH) research project grants that were awarded to principal investigators, stratified by highest degree, 148 5-3 Success rate of National Institute of Mental Health (NIMH) research project grant applications, stratified by degree of the principal investigator, 149 5-4 Total number (table) and percentage (graph) of all, female, and international medical graduate (IMGs) physicians declaring research as their primary activity, 1970–2000, 152 5-5 Number of international medical graduates (IMG) and U.S. medical graduates who entered psychiatry as PGY1 residents, 155 BOXES 2-1 Rationale for Incorporating Research Training into the Residency Experience, 38 3-1 Requirements Prescribed by the Psychiatry Residency Review Committee for Accredited Programs in Adult (General) Psychiatry, 73 3-2 Requirements Prescribed by the Psychiatry Residency Review Committee for Accredited Programs in Child and Adolescent Psychiatry, 74 3-3 Summary of Topics Included on Written Portion of Psychiatry Board Examination, 81 5-1 Nonsalary Benefits of a Research Career, 144 6-1 Three Studies Suggesting the Need for Psychiatrist-Researchers, 170–171