Executive Summary

Abstract: The neural and behavioral sciences have advanced tremendously in recent years, and there has been a concomitant increase in public awareness of mental disorders. Psychiatrists are on the front line of treating mental illness. Some psychiatrists also serve as patient-oriented researchers, advancing psychiatric care through investigation aimed at helping those with or at risk for mental disorders. Unfortunately, the number of psychiatrist-researchers does not appear to be keeping pace with the unparalleled needs that currently exist in clinical brain and behavioral medicine. The need is especially acute in child and adolescent psychiatry. In this context, the National Institute of Mental Health asked the Institute of Medicine (IOM) to convene a committee to study research training during psychiatric residency. The IOM committee was charged with considering (1) the goals of psychiatric residency training, (2) programs that train researchers successfully, (3) obstacles to efficient research training, and (4) strategies for overcoming those obstacles.

The committee found that significant influences on research training span three major conceptual categories: regulatory, institutional, and personal factors. Cutting across these factors are the ubiquitous and overlapping issues of time and money, and the competing demands of patient-care activities. A considerable time investment—2 to 4 years—beyond core clinical training is typically required for successful research training. Therefore, the committee concluded that more and better residency-based research training may have the important and dual benefits of optimizing the length of training for, and solidifying research career interests of, greater numbers of junior psychiatrists.

Regarding regulatory factors, a review of the psychiatry residency accreditation requirements led the committee to conclude that these requirements should be modified to afford more training time for research experiences and general research literacy. Institutional factors of greatest importance were found to be supportive leadership and the involve-



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Research Training in Psychiatry Residency: Strategies for Reform Executive Summary Abstract: The neural and behavioral sciences have advanced tremendously in recent years, and there has been a concomitant increase in public awareness of mental disorders. Psychiatrists are on the front line of treating mental illness. Some psychiatrists also serve as patient-oriented researchers, advancing psychiatric care through investigation aimed at helping those with or at risk for mental disorders. Unfortunately, the number of psychiatrist-researchers does not appear to be keeping pace with the unparalleled needs that currently exist in clinical brain and behavioral medicine. The need is especially acute in child and adolescent psychiatry. In this context, the National Institute of Mental Health asked the Institute of Medicine (IOM) to convene a committee to study research training during psychiatric residency. The IOM committee was charged with considering (1) the goals of psychiatric residency training, (2) programs that train researchers successfully, (3) obstacles to efficient research training, and (4) strategies for overcoming those obstacles. The committee found that significant influences on research training span three major conceptual categories: regulatory, institutional, and personal factors. Cutting across these factors are the ubiquitous and overlapping issues of time and money, and the competing demands of patient-care activities. A considerable time investment—2 to 4 years—beyond core clinical training is typically required for successful research training. Therefore, the committee concluded that more and better residency-based research training may have the important and dual benefits of optimizing the length of training for, and solidifying research career interests of, greater numbers of junior psychiatrists. Regarding regulatory factors, a review of the psychiatry residency accreditation requirements led the committee to conclude that these requirements should be modified to afford more training time for research experiences and general research literacy. Institutional factors of greatest importance were found to be supportive leadership and the involve-

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Research Training in Psychiatry Residency: Strategies for Reform ment of research faculty as residency educators and mentors. A review of personal factors revealed motivation and drive, family demands, gender, and race as important factors relevant to research training in psychiatry. This finding led the committee to conclude that a more diverse group of trainees needs to be persuaded that research careers in psychiatry are worthwhile. Greater financial incentives (through stipend supplements or debt repayment) and more aggressive promotion of the benefits of participation in psychiatric research are recommended as strategies to enhance trainee recruitment. In addition to time and money, overarching themes of this report are that residency-based research is limited because of the demands of clinical training, and thus that successful research training typically requires the linkage of residency to postresidency research fellowships. There is little evidence to support any particular approach to training patient-oriented investigators. Given that the existence of a large research effort (i.e., many investigators and substantial funding) is the most salient feature of successful programs, child and adolescent psychiatry divisions and small programs in general will likely require outside collaborations to develop a critical mass of resources for effective research training. Finally, while there are numerous efforts under way to enhance research training in psychiatric residency, the committee recommends the formation of a national coordinating body to develop, implement, and evaluate strategies toward that goal. STUDY CONTEXT Mental disorders, such as schizophrenia, severe depression or anxiety, and substance abuse, represent some of the most debilitating and vexing of human diseases. Recent years have seen considerable advances in the brain and behavioral sciences, but the burden of mental disorders remains very high, accounting for approximately 15 percent of all human disease (Murray and Lopez, 1996). Understanding of the mechanisms underlying such disorders is expanding at a tremendous rate, but remains limited compared with the vast complexity of human neurobiology and behavior (Charney et al., 2001; Kandel et al., 2000). Carefully formulated research in a variety of disciplines is clearly needed to accelerate progress in mental health care, and this research needs to be skillfully aimed at questions relevant to patients who suffer from or are at risk for mental disorders.

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Research Training in Psychiatry Residency: Strategies for Reform Research Involvement of Psychiatrists By virtue of their medical school and clinical residency training, psychiatrists have expertise in the diagnosis and treatment of serious mental disorders and in the neurobiological basis of these disorders. It therefore appears obvious that they would be interested in and capable of contributing to the mental health research effort. Yet while many psychiatrists conduct research, a 1989 survey found that only 15 percent of psychiatrists who are faculty at U.S. medical schools spent more than half of their professional time engaged in research (Pincus et al., 1993), and more recent surveys conducted in 1999 and 2000 showed that fewer than 2 percent of all U.S. psychiatrists consider research their dominant activity (Association of American Medical Colleges [AAMC], 2002b). Data from the American Psychiatric Association (APA) indicate that, along with these low baseline rates of research involvement, research fellowships to train young psychiatrists appear to be on the decline (APA, 1997a; Fenton, 2002; Guerra and Regier, 2001; Nevin and Pincus, 1992; Steele and Pincus, 1995). Overall, then, research training and research involvement by psychiatrists appear to be limited and may be decreasing (Fenton, 2002; Halpain et al., 2001; Hyman, 2002b; Kupfer et al., 2002). Genesis of the Study and the Study Charge The National Institute of Mental Health (NIMH) is at the center of U.S. efforts to advance mental health and is a principal source of funding for psychiatrist trainees and established researchers. In 2001, NIMH awarded $230 million in education and research grants to psychiatrist-investigators (data furnished by NIMH, Office of Science Policy and Program Policy, February 21, 2003). NIMH believes the number of psychiatrist-researchers is not keeping pace with the increased funding and unparalleled opportunities that exist in patient-oriented mental health research (Fenton, 2002; Hyman and Fenton, 2003; Shore et al., 2001). As part of a larger strategy to address this problem, NIMH asked the Institute of Medicine (IOM) to convene an expert committee that would evaluate the current goals of psychiatry residency training and consider strategies for enhancing research training during or in close proximity to residency. Specifically, the IOM committee was asked to address the following four issues in the context of adult, and child and adolescent psychiatric residency: (1) the goals of training, with an emphasis on both core research training and training trajectories to facilitate patient-

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Research Training in Psychiatry Residency: Strategies for Reform oriented research career development; (2) programs that successfully train patient-oriented researchers; (3) obstacles to efficient research training at both research-intensive and other institutions, and (4) strategies for overcoming those obstacles. CONCLUSIONS AND RECOMMENDATIONS Before presenting the recommendations of this report the committee must caution readers that data regarding both the magnitude of the problem, and the effectiveness of proposed solutions, were limited. Limitations stemmed from a number of sources. First, it is challenging to estimate the physician workforce across medical specialties (Council on Graduate Medical Education [COGME], 2000). Second, in psychiatry and most medical disciplines there are many non-physician investigators who make invaluable contributions to clinical research, therefore, workforce estimates are further complicated by considering those experts (Fang and Meyer, 2003). Finally, documentation of residency-based clinical research education is scarce and often imprecise thereby inhibiting extensive and objective evaluation (Hebert et al., 2003; Sheets and Anderson, 1991). Because of these limitations, the committee drew heavily from its collective expertise and experience in making its recommendations. Through a review of the existing literature, as well as numerous personal contacts, the committee identified the need to place residency in the broad longitudinal continuum of physician training—from the undergraduate years, to medical school, residency, fellowship, and beyond—when addressing research training needs for psychiatry residents. The committee also identified three distinct sets of factors that influence research training during or in close proximity to psychiatric residency: Regulatory factors, comprising program accreditation and individual certification requirements that are governed by the Psychiatry Residency Review Committee (RRC) under the auspices of the Accreditation Council for Graduate Medical Education (ACGME) and by the American Board of Psychiatry and Neurology (ABPN). Both the Psychiatry RRC and the ABPN are independent, not-for-profit bodies that have historically placed much greater emphasis on clinical than on research training issues. Institutional factors, encompassing the research and research-training milieu of individual residency programs. The training environment comprises curriculum, departmental and institutional faculty and

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Research Training in Psychiatry Residency: Strategies for Reform leadership, facilities and finances, and the existing portfolio of ongoing research projects. Personal factors, including innate ability and drive, educational debt, family responsibilities, race, and gender. Finally, the cross-cutting issues of time, money, and clinical demands relate to and even transcend many of the above factors. Clinical demands are especially pertinent because residents need to diagnose and treat patients as a means of gaining practical experience, and because patient needs are often more urgent than patient-oriented research. Residency as Part of a Continuum of Training Central to program infrastructure are the duration and timing of research training. After careful consideration of research training in the context of residency, the committee concluded that psychiatry residency is a pivotal interval during which preliminary research training should be offered. It represents an opportunity to (1) prepare all residents for the lifelong practice of evidence-based medicine (Mulrow and Lohr, 2001; Sackett et al., 1996), (2) provide some residents with initial research experiences that may launch them into a patient-oriented research career, and (3) sustain the research interests of trainees with previous research experience (e.g., M.D./Ph.D.’s). That having been said, the committee also concluded that postresidency fellowship training is required to give medical trainees the skills and knowledge needed to embark on a career as an independent, productive researcher. Fellowship training beyond residency is important preparation for a sustained career in research, both within and outside of psychiatry (Davis and Kelley, 1982; Dial et al., 1990; Dunn et al., 1998; Haviland et al., 1987; Pincus et al., 1993; Ringel et al., 2001). These fellowships take place immediately after residency and last 1 to 3 years. Internal medicine, pediatrics, and other medical specialties rely on extended research training and typically couple it with subspecialty training. By contrast, psychiatry seems to have developed subspecialty tracks (e.g., geriatrics) which do not usually include substantive research training goals. The more research-intensive departments in psychiatry place heavy emphasis on offering research fellowships and on connecting those fellowships to core residency training, but most training programs in psychiatry do not appear to facilitate such connectivity. To foster this connectivity between residency and research fellowships in psychiatry, the committee makes the following recommendation:

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Research Training in Psychiatry Residency: Strategies for Reform Recommendation 2.1.1 Departments of psychiatry should organize optional research experiences and mandatory research didactics in residency as early steps in research career development pathways, leading from residency to a junior faculty appointment. Federal and private agencies should expand mechanisms that encourage psychiatry trainees to enter and move, without interruption, from residency to a research fellowship to a faculty position, all designed to promote independence as a patient-oriented investigator. Regulatory Factors The two regulatory bodies with the greatest influence over psychiatry residency training are the ABPN and the Psychiatry RRC. These two bodies aim to safeguard consumer health by ensuring that all residency graduates are competent to deliver quality psychiatric care. The ABPN certifies individuals, through an examination process that occurs after residency has been completed, while the RRC mandates minimal standards to which programs must adhere to be accredited to train future psychiatrists. A review of the RRC requirements for adult and for child and adolescent psychiatry led the committee to conclude that the clinical requirements could be reduced to foster greater flexibility in training that might include offering research training electives (ACGME, 2000a; 2000b). This reduction would involve limiting some of the timed and untimed requirements that have been added in recent years. For example, the psychotherapy requirement, which includes the achievement of competency in five broad areas, could be reduced to knowledge in those five areas and competency in a subset. Additionally, inpatient service of 9 months could be reduced to 6 months to allow time for other experiences. Given the apparent universal belief that protected time for research activity is critical for research success (Costa et al., 2000; DeHaven et al., 1998; Griggs, 2002; McGuire and Fairbanks, 1982; Raphael et al., 1990; Roberts and Bogenschutz, 2001; Schrier, 1997; Shine, 1998; Shore et al., 2001), the committee makes the following recommendation: 1   For ease of reference, the committee’s recommendations are numbered according to the chapter of the main text in which they appear followed by the order in which they appear in that chapter.

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Research Training in Psychiatry Residency: Strategies for Reform Recommendation 3.1. The American Board of Psychiatry and Neurology and the Psychiatry Residency Review Committee should make the requirements for board certification and residency accreditation more flexible so research training can occur during residency at a level that significantly increases the probability of more residents choosing research as a career. The committee further recommends that residents who successfully fulfill core requirements at an accelerated pace, with competency being used as the measure, be allowed to spend the time thus made available to pursue research training. The ABPN and the Psychiatry RRC should provide written guidelines and ongoing support to assist programs in incorporating research experiences into all years of residency. This recommendation is aimed at optimizing core training by streamlining some of the redundant or overly ambitious requirements of that training, and by permitting programs and individuals the opportunity to tailor larger portions of their training with elective experiences that might include “hands-on” research activity. The recommendation further aims to entice outstanding residents to undertake research activity by rewarding fast-paced attainment of clinical competency with greater opportunities for early research involvement. Implementation of this recommendation will depend on enabling guidelines from both the RRC and the ABPN. This recommendation is consistent with an ACGME initiative aimed at competency-based rather than time-based training (ACGME, 2002b). While the committee advocates increased flexibility in clinical requirements, we also conclude that the research requirements of residency training should be strengthened to facilitate the field’s progression as an evidence-based discipline (Mulrow and Lohr, 2001; Sackett et al., 1996). Although the requirements of the Psychiatry RRC do characterize research experiences and didactics as clear “shoulds,” most programs appear to offer very little in the way of research training for their residents (Balon and Singh, 2001). Even the strongest programs usually delay research exposure until the last 2 years of the residency. Accordingly, the committee makes the following recommendation: Recommendation 3.2. The American Board of Psychiatry and Neurology and the Psychiatry Residency Review Committee should require patient-oriented

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Research Training in Psychiatry Residency: Strategies for Reform research literacy as a core competency of residency training in adult and child and adolescent psychiatry. Program directors and the American Board of Psychiatry and Neurology should evaluate residents on these competencies. This recommendation should be implemented by strengthening the language of the current Psychiatry RRC requirements to indicate that all curricula must address research design and methods as preparation for the lifelong practice of evidence-based medicine. The ABPN should enforce the requirement for literacy in patient-oriented research by adding more questions on research to the certification examination. Content for program didactics and for the examination in the context of residency training could come from any number of published works on clinical research in general or in psychiatry in particular (Blazer and Hays, 1998). A review of various published curricula indicates that research literacy in psychiatry should include knowledge in at least the following areas: epidemiology, study design, biostatistics, integrated clinical neural and behavioral science, research ethics, and grant and manuscript writing skills. This knowledge could be addressed by adding content to the in-training and credentialing examinations that are a standard part of psychiatrists’ transition to independent practice. Since expertise will be needed to craft guidelines for the competencies noted above, the following recommendation is important: Recommendation 3.3. The organizations that nominate members for the Psychiatry Residency Review Committee and the American Board of Psychiatry and Neurology should include on their nomination lists substantial numbers of extramurally funded, experienced psychiatrist-investigators who conduct patient-oriented research. Research experience is not currently an explicit requirement for nomination to serve on the RRC or the ABPN. It is the committee’s view that at least some of the slots on those regulatory bodies should be filled with skilled patient-oriented researchers. Doing so would greatly increase the probability that accreditation and certification policies will reflect the input of knowledgeable patient-oriented researchers. Implementation of this recommendation could be effected by one or more of the nominating bodies (e.g., American Psychiatric Association, American Medical Association) or by a change in the nomination policies of

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Research Training in Psychiatry Residency: Strategies for Reform the ACGME (the umbrella organization for all RRCs) and the ABPN to mandate the inclusion of a certain number of patient-oriented researchers (ACGME, 2002c). As researchers are a small minority of all psychiatrists, a key constraint on the implementation of this recommendation is the willingness of researchers to commit some time to the educational mission. To facilitate that willingness, leaders in psychiatry should consider how to make such service responsibilities tenable. For example, service on the ABPN executive board requires a commitment of 45 days per year (personal communication, S. Scheiber, ABPN, April 5, 2003). Such a service requirement could be impossible for someone responsible for an ongoing research program unless his/her department chair (or extramural funding agency) offered some reprieve or extension on existing obligations, or unless the ABPN could devise some way to reduce the time commitment of key contributors. Finally, it should be emphasized that, while RRC and ABPN policies clearly set standards for the entire field, these organizations are not directly responsible for clinical or research training. Local institutions are in charge of such training. If they are going to be successful at training new researchers, the individual programs themselves must strive to provide the necessary resources and opportunities, including research time, mentors, and a culture that genuinely supports and values the importance of generating new clinical knowledge. Institutional Factors Training Resources Issues associated with funding, mentoring, and resident scheduling appear to be the chief constraints on research training in residency. Support for residency training is heavily dependent on Medicare funding for graduate medical education. That funding stream is under increasing pressure as federal and private payers seek ways to minimize health care costs. Research is not generally considered part of core residency training. As a result, funding for research activity often needs to be independently justified and obtained either from extramural grants or from discretionary internal funds (e.g., endowments, profits from practice plans). Furthermore, leadership at medical centers have control over how funds are distributed and they set expectations regarding trainee and faculty activity through institutional mechanisms such as promotion policies and

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Research Training in Psychiatry Residency: Strategies for Reform general resource allocation. Therefore, the committee believes the following recommendation is critical to research training in psychiatry: Recommendation 4.1. The broad psychiatry community should work more aggressively to encourage university presidents, deans and hospital chief executive officers to give greater priority to the advancement of mental health through investments in leadership, faculty, and infrastructure for research and research training in psychiatry departments. Although this recommendation is likely relevant to other branches of medical research, psychiatric research is of particular importance in this regard. This is the case because current opportunities in brain and behavioral research are so great, and because mental illness is the object of stigma and cost containment efforts that impede access to care as well as equitable reimbursement for mental health services (U. S. Department of Health and Human Services [DHHS], 1999; Frank et al., 2001b). Department chairs and other leaders could promote psychiatric research by developing a business case delineating the financial and societal benefits likely to result from mental health research. At the same time, these leaders should also inform medical students and residents regarding the extraordinary intellectual challenges that accompany research in psychiatry. Mentoring is the ingredient cited most frequently as necessary for effective research training (Balon and Singh, 2001; DeHaven et al., 1998; IOM, 1994; Pincus et al., 1995). Limits on mentoring are also frequently noted as a barrier to effective research training (Lewinsohn et al., 1998). A logical extension of this observation is that more incentives are needed to encourage senior researchers to act as mentors to the next generation of research psychiatrists. Accordingly, the committee makes the following recommendation: Recommendation 4.2. Academic institutions and their psychiatry residency training programs should reward the involvement of patient-oriented research faculty in the residency training process. The National Institute of Mental Health should take the lead in identifying funding mechanisms to support such incentives. This recommendation targets in particular smaller institutions with limited research programs that are likely to have difficulty attracting the most research-minded applicants seeking the most varied research train-

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Research Training in Psychiatry Residency: Strategies for Reform ing experience available. Such programs will be less competitive in attracting trainees with prior research experience, so that greater training and supervision will be required before their residents can extend the productivity of research mentors. Especially for less research-intensive programs, the committee encourages mechanisms to cover the additional mentoring costs associated with training research-naive residents. When on-site mentoring is not possible, a remote network (e.g., via the Internet) might be developed to give trainees the opportunity to reach beyond their home institution for scientific and career advice. At a minimum, such a network might assist residents with transient issues by providing occasional consultations; in some instances, however, it could lead residents to research fellowships or other even longer-term research collaborations with senior investigators. Senior researchers might be willing to act as remote mentors for a consulting fee and/or for the opportunity to establish collaborative or trainee recruitment links outside their institutions. Development of Research Curricula In addition to institutional leadership and mentoring, the committee reviewed generic clinical research training programs and several set specifically in the context of the psychiatric residency. These programs are highly variable. Generic programs range from 1-year certificates to multiyear programs that culminate with a Ph.D. degree. Although this range appears to be geared in part toward the broad mix of applicants, an AAMC task force concluded that such program variability in general reflects imprecision regarding the formal constitution of clinical research training (AAMC, 1999). Common practices are nevertheless apparent from a review of existing programs and published descriptions. Most programs offer some research training in the later years of residency, and the most research-intensive institutions route their research-oriented graduates toward additional training, usually in the form of a fellowship. Hands-on research participation is encouraged. Course subject matter typically includes epidemiology, grant and paper writing, integrated neural and behavioral science, and research ethics. Little has been done to integrate substantial research training into all or even most of the residency years (Balon and Singh, 2001). Additionally, existing curricula typically are not validated by long-term follow-up studies to determine whether trainees were actually prepared to move into patient-oriented research careers or even to practice evidence-based medicine more efficiently. Given that it was dif-

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Research Training in Psychiatry Residency: Strategies for Reform ficult for the committee to identify truly successful programs beyond reputation, we make the following recommendation: Recommendation 4.3. The National Institute of Mental Health, foundations, and other funding agencies should provide resources to support efforts to create competency-based curricula for research literacy and more comprehensive research training in psychiatry that are applicable across the spectrum of adult (general) and child and adolescent residency training programs. Supported curriculum development efforts should include plans for educating faculty to deliver each new curriculum, as well as plans for evaluating each curriculum’s success in training individuals to competency and in recruiting and training successful researchers. These curricula should be aimed at sparking residents’ interest in a lifelong career in patient-oriented research without interfering with core clinical training. The principal aim of this recommendation, however, is to ensure that all residents are adequately introduced to the concepts of research and that research training is not merely an afterthought to residency education. Thus the recommendation is focused on ensuring that all residency programs offer training that can contribute to the expansion of a patient-oriented research effort in psychiatry. Even residents who intend to become clinicians should be introduced to the concepts and findings of patient-oriented research as a necessary complement to their clinical training. Curricula should be developed using established educational principles; it is especially important to include evaluation phases to verify the utility of the curricula in the training of patient-oriented psychiatrist-researchers and evidence-based practitioners (Sheets and Anderson, 1991). Novel ways to integrate research training into the residency experience should also be considered. The committee believes that, since psychiatric training programs vary considerably in terms of size and local expertise, they should be viewed along a hierarchical research training continuum that ranges from those providing basic research literacy to those training large numbers of patient-oriented psychiatrist-researchers. This continuum (detailed in the full report) can be used as a guide for programs interested in moving to a higher level of research training. It can also be used to implement the following recommendation, which is aimed at encouraging targeted

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Research Training in Psychiatry Residency: Strategies for Reform NIMH extramural support for the emergence of new mid- and high-range centers of excellence in patient-oriented research training: Recommendation 4.4. The National Institute of Mental Health should support those departments that are poised to improve their residency-based research training to achieve measurable increases in patient-oriented research careers among their trainees. Support for such programs should include funds to: Hire faculty and staff dedicated to research and research training efforts. Acquire equipment and enhance facilities for research training. Initiate pilot and/or short-term research activities for residents. Educate adult and child and adolescent residency training directors and other faculty in how to promote and guide research career planning. Personal Factors Individuals considering patient-oriented research in psychiatry are likely influenced by a number of personal factors. Some of these factors are so intrinsic that it is difficult to imagine the formal educational process, especially in adulthood, having a large impact on them. Perhaps the best any discipline can do with regard to candidates having exceptional drive or talent is to encourage them toward that specialty. There is some evidence that psychiatry may not be competitive in attracting the top or most research-intensive medical students (Feifel et al., 1999; Nicholson, 2002), despite unparalleled opportunities in the clinical brain and behavioral sciences. Part of the problem may be the compensation of psychiatrists as compared with that for other disciplines. The anticipated salaries for psychiatrists, whether academic or clinical, are near the bottom of the physician pay scale (AAMC, 2002b; Bureau of Labor Statistics, 2002). Concerns about loan repayment and overall financial well-being may discourage potential patient-oriented researchers from extended research training, which would further delay them from achieving their full earning potential. Although financial incentives for research experiences in core residency would create unacceptable compensation inequities, in-

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Research Training in Psychiatry Residency: Strategies for Reform centives for pursuing a research fellowship are limited only by the availability of funds. Accordingly, another recommendation the committee makes is as follows: Recommendation 5.1. The National Institute of Mental Health and other funding agencies should seek mechanisms to offer increased financial incentives, such as loan repayment, to trainees who commit to research training and research involvement beyond core psychiatry residency. Although financial expectations play a role in the career decisions of medical students and residents, trainees are equally if not more concerned about other issues, such as lifestyle and the intellectual content of their selected profession. Furthermore, new physicians are understandably anxious about the challenges involved in securing long-term research funding and the workload associated with a research career. The committee observed that in recent years, many well-respected medical experts have written extensively about the problems associated with clinical research without promoting the endeavor as an exciting option for new physicians (Lieberman, 2001; Schrier, 1997; Shine, 1998). The preface to a recent opinion piece by an established psychiatrist-researcher, for example, notes that research careers are neither glamorous nor intellectually exciting, but instead are tedious and often involve considerable delayed gratification (Lieberman, 2001). While such characterizations are sometimes true of any difficult endeavor, the committee is concerned that they may overshadow the many positive aspects of a research career. Thus we make the following recommendation: Recommendation 5.2. Individuals and institutions involved in the education and mentoring of medical students, residents and fellows should strongly convey to these trainees the benefits (professional and societal) associated with patient-oriented research in psychiatry. Promotion strategies might include support for student interest groups; brochures, websites, and other media; and summer research training opportunities. This recommendation is based on the belief that research offers a number of nonsalary benefits (e.g., a broad network of colleagues, involvement in new discoveries). This recommendation also encourages

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Research Training in Psychiatry Residency: Strategies for Reform recruitment strategies that emphasize the growing scientific evidence base underlying the practice of modern psychiatry (Charney et al., 2001; Hamburg, 2002). Finally, the demographics of the psychiatry workforce suggest that special measures are needed to ensure that talented women and international medical graduates are encouraged to pursue careers in patient-oriented research. Additionally, as is the case for all branches of medicine, greater involvement of underrepresented minorities is imperative if psychiatry is to offer the most responsive care to a diverse U.S. population. Accordingly, the committee makes the following three recommendations: Recommendation 5.3. Departments of psychiatry, supported by the National Institute of Mental Health and other psychiatric organizations, should provide leadership in recruiting and retaining more women for psychiatry research careers. Such efforts should include: Increasing part-time training and job sharing opportunities. Developing a critical mass of female role models and mentors. Working with institutions to improve child day care programs. Addressing institutional promotion and tenure issues, such as the tenure clock, that may be perceived as barriers to female trainees. Educating women about the time flexibility of research careers. Recommendation 5.4. Psychiatry training programs, academic medical centers, psychiatry organizations, and the federal government should work together to facilitate research training for international medical graduates who have the potential to make outstanding research contributions to psychiatry. Retention of the most productive of these international graduates in U.S. academic psychiatry programs should also be a joint effort.

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Research Training in Psychiatry Residency: Strategies for Reform Recommendation 5.5. Psychiatry research training programs should increase the numbers of underrepresented minority researchers by employing the following strategies: Recruit minority faculty in multiple disciplines to serve as role models and mentors. Pursue funding from NIMH and other funding agencies that support minority trainees and faculty. Inform more minority psychiatrists about research training and other funding opportunities. Cross-Cutting Themes and Future Directions Two points emerged from the committee’s broad review of the problem of encouraging psychiatry residents to pursue careers in research. First, numerous factors influence a psychiatry resident’s decision about a research career. Second, despite numerous national and local efforts, there is a paucity of data about which methods are truly effective at fostering research career development and success among psychiatrists. Accordingly, the recommendations of this report are based in large part upon the expert opinions of the committee members. Regarding the first point, there is a fairly extensive body of opinion and anecdotal evidence to support the relevance of each of the regulatory, institutional, and personal factors summarized above. Detailed analyses of the factors impacting research training are quite rare, however, and the committee is aware of very few studies that attempt to quantify the relative contribution of specific variables (Kruse et al., 2003; Pincus et al., 1995). As an example of the uncertainty that remains, it is currently impossible to determine whether spending more on mentors or on enhancing trainee recruitment would yield greater gains in the numbers of patient-oriented researchers in psychiatry. Most of the committee’s recommendations are likely relevant to physician-investigators outside of psychiatry. However, issues of stigma and the history of the profession weigh more heavily for psychiatry than for other medical specialties with regard to research and research training (DHHS, 1999; Eisenberg, 2002). Additionally, a theme of this report is that what is true for adult psychiatry is even more so for child and adolescent psychiatry. Specifically, there appears to be a particular shortage

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Research Training in Psychiatry Residency: Strategies for Reform of child and adolescent psychiatrists and psychiatrist-researchers despite the many challenges posed by mental disorders affecting the nation’s youth (Kim et al., 2001). Finally, the committee found that data regarding (1) the need for psychiatrist researchers and (2) the success and precise strategies of individual programs that purport to train them, were both lacking despite strong interest and action by numerous stakeholders. Although there is evidence supporting the hypothesis that an increase in psychiatrist-researchers would benefit the nation’s mental health, this contention has not been well substantiated in a systematic and scientific way. Similarly, while there are many isolated efforts to train psychiatrist researchers, there is at best implicit coordination between some of these efforts suggesting that increase cooperation may yield benefits to the psychiatric research workforce more broadly. Better data on the numbers of psychiatrist-researchers and their contribution to the nation’s mental health will likely be necessary to convince policy makers and medical educators that the training of psychiatrist-researchers is worthy of increased investment. Given this need for more information, and the need to insure coordination among various groups engaged in research training, the committee makes the following overarching recommendation: Recommendation 6.1. The National Institute of Mental Health should take the lead in organizing a national body, including major stakeholders (e.g., patient groups, department chairs) and representatives of organizations in psychiatry, that will foster the integration of research into psychiatric residency and monitor outcomes of efforts to do so. This group should specifically collect and analyze relevant data, develop strategies to be put into practice, and measure the effectiveness of existing and novel approaches aimed at training patient-oriented researchers in psychiatry. The group should have direct consultative authority with the director of the National Institute of Mental Health, and also should provide concise periodic reports to all interested stakeholders regarding its accomplishments and future goals. Many national organizations, including the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry, are already directly addressing the problem of research training in psychiatry. This recommendation aims to encourage maximal coop-

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Research Training in Psychiatry Residency: Strategies for Reform eration among these organizations so that redundancy is avoided, and systematic and large-scale assessments of best practices can be undertaken. The recommendation is also intended to bring together stakeholders in psychiatry and related disciplines to pursue the goal of defining more precisely the specific contributions psychiatrists can and have made to biomedical research. Table ES-1 summarizes the committee’s recommendations and identifies the obstacles to research training in psychiatric residency addressed by each.

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Research Training in Psychiatry Residency: Strategies for Reform TABLE ES-1 Summary of Recommendations Topic Number   Recommendation Obstacle Addressed Longitudinal Perspective 2.1 Foster coordinated multiyear research training experiences. Research opportunities are fragmented across the multiple levels and years of training. Regulatory Factors 3.1 Increase the flexibility of training requirements. Clinical requirements are excessive and prevent tailored training. 3.2 Require research literacy. Many training programs lack research education components. 3.3 Require researcher membership on regulatory bodies. Researchers are not sufficiently involved in setting expectations for training curricula and achievement of competencies. Institutional Factors 4.1 Encourage executives to invest in mental health research. Resources to support research training are limited; stigma works against optimal mental health care funding. 4.2 Encourage research faculty involvement. Researchers often are not involved in direct resident training. 4.3 Create patient-oriented research training curricula. Curricula are needed that incorporate research training across the range and time constraints of residency programs. 4.4 Support emerging programs. Resources to move programs to the next level of research training are scarce. Personal Factors 5.1 Increase financial compensation to trainees. Education debt and low compensation deter the choice of a research career. 5.2 Develop strategies to attract trainees to patient-oriented research. Trainees have pessimistic views of research careers and can be uninformed about research opportunities. 5.3 Develop women researchers. Talent is underutilized. 5.4 Develop international medical graduate researchers. Talent is underutilized. 5.5 Develop minority researchers. Workforce diversity is lacking; talent is underutilized. Overarching Recommendation 6.1 Establish a national coordinating effort. Monitoring data are lacking, and there is no centralized plan for research training.

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