1
Introduction

STUDY CONTEXT

The Burden of Mental Illness

Recent global estimates suggest that at any one time, 450 million persons suffer from neuropsychiatric disorders, including depression and/or mania, schizophrenia, epilepsy, alcohol and other addictive disorders, dementias, anxiety disorders, and serious sleep disturbances (World Health Organization [WHO], 2001). In terms of disability-adjusted life years, a measure that combines estimates of disease morbidity and mortality, mental disease ranks second only to cardiovascular disorders, and first if one includes the burden of suicide and substance abuse. Specifically, 1991 data coalesced by WHO, Harvard University, and others indicate that 15.4 percent of the total disease burden in industrialized countries can be directly attributed to mental disorders.2 By comparison, only cardiovascular diseases rank higher, at 18.6 percent. Cancer is a close third, at 15 percent, while respiratory diseases (6.2 percent) and alcohol-related morbidity (4.7 percent) are a distant fourth and fifth, respectively (U.S. Department of Health and Human Services [DHHS], 1999; Murray and Lopez, 1996).

Millions of Americans experience the debilitating and sometimes deadly consequences of mental illness: 10 million suffer from a major depressive disorder (National Institute of Mental Health [NIMH], 2001c), over 2 million adults suffer from schizophrenia (Hoyert et al., 1999), and 30,000 individuals commit suicide each year (NIMH, 2001c). Serious mental disorders also afflict a large number of children. Severe or extreme functional impairment related to such diseases (e.g., depression, anorexia nervosa, violent behaviors, and autistic-spectrum abnor-

2  

Mental disorders include unipolar major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and self-inflicted injuries (e.g., suicide). Excluded are substance-abuse disorders that include alcohol addiction.



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Research Training in Psychiatry Residency: Strategies for Reform 1 Introduction STUDY CONTEXT The Burden of Mental Illness Recent global estimates suggest that at any one time, 450 million persons suffer from neuropsychiatric disorders, including depression and/or mania, schizophrenia, epilepsy, alcohol and other addictive disorders, dementias, anxiety disorders, and serious sleep disturbances (World Health Organization [WHO], 2001). In terms of disability-adjusted life years, a measure that combines estimates of disease morbidity and mortality, mental disease ranks second only to cardiovascular disorders, and first if one includes the burden of suicide and substance abuse. Specifically, 1991 data coalesced by WHO, Harvard University, and others indicate that 15.4 percent of the total disease burden in industrialized countries can be directly attributed to mental disorders.2 By comparison, only cardiovascular diseases rank higher, at 18.6 percent. Cancer is a close third, at 15 percent, while respiratory diseases (6.2 percent) and alcohol-related morbidity (4.7 percent) are a distant fourth and fifth, respectively (U.S. Department of Health and Human Services [DHHS], 1999; Murray and Lopez, 1996). Millions of Americans experience the debilitating and sometimes deadly consequences of mental illness: 10 million suffer from a major depressive disorder (National Institute of Mental Health [NIMH], 2001c), over 2 million adults suffer from schizophrenia (Hoyert et al., 1999), and 30,000 individuals commit suicide each year (NIMH, 2001c). Serious mental disorders also afflict a large number of children. Severe or extreme functional impairment related to such diseases (e.g., depression, anorexia nervosa, violent behaviors, and autistic-spectrum abnor- 2   Mental disorders include unipolar major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and self-inflicted injuries (e.g., suicide). Excluded are substance-abuse disorders that include alcohol addiction.

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Research Training in Psychiatry Residency: Strategies for Reform malities) is estimated to occur in 4 to 10 percent of individuals under the age of 18 (Friedman et al., 1996; Kim et al., 2001; Leebens et al., 1993). Diagnosable mental illness of all severities is believed to exist in 12 to 24 percent of school-aged children (Foa et al., 2000; Friedman et al., 1996; Kim et al., 2001; Shaffer et al., 1996). Increasing Societal Awareness of Mental Illness In response to such mental health problems, and given the promise of brain and behavioral research to address these problems, the 1990s was officially dubbed the “the decade of the brain,” and entry into the new millennium has been assigned a complementary label, “the decade of behavior” (Decade of Behavior, 2001; Library of Congress, 2000). Between 1999 and 2002, the U.S. Surgeon General released several reports focused on mental health, including two broad-ranging reports on the subject (one general and one focused on ethnic, cultural, and racial issues), as well as reports on tobacco addiction and on youth violence (DHHS, 2001a; 2001b; 2001c; 2002). In 2001, WHO also released a comprehensive report on the state of global mental health (WHO, 2001). In 2002, a White House Commission on the U.S. mental health care delivery system released its interim report (President’s New Freedom Commission on Mental Health, 2002). All of the above reports detail the extraordinary gains that have been made in mental health care, including advances in integrative neuroscience and health services research. Yet they also point to substantial gaps in basic and clinical scientific knowledge related to the treatment and prevention of mental diseases, gaps that must be filled by the efforts of a sophisticated workforce consisting of physicians, epidemiologists, psychologists, and neuroscientists. Collectively, these reports reflect the unambiguous emergence of mental health care as a key priority in the United States and internationally. Advances in Mental Health Care Substantial and increasing public awareness and activity regarding brain function and disease have evolved along with impressive research progress in the neural and behavioral sciences. Numerous innovations and discoveries can be cited that enhance our understanding of the human brain and the delivery of care to those who suffer from mental disorders. Genetic and other molecular research has exposed elements of the

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Research Training in Psychiatry Residency: Strategies for Reform biological underpinnings of several severe behavioral disorders, including depression, schizophrenia, dementia, and substance abuse (e.g., Charney et al., 2001; Hyman, 2002a). Neuroimaging advances have permitted noninvasive, in vivo views of brain anatomy, metabolism, and dynamic function (Bertolino and Weinberger, 1999; Durston et al., 2001; Fu and McGuire, 1999; Hendren et al., 2000; Malhi et al., 2002; Marder and May, 1986; Moresco et al., 2001; Royall et al., 2002; Yanai, 1999). Pharmacologic and psychologic therapies, alone or in combination, have demonstrated considerable efficacy in treating a variety of mental disorders, including schizophrenia, dementia, depression, anxiety and panic disorders, obsessive-compulsive disorder, hyperactivity, inattention, post-traumatic stress disorder, and substance abuse (Barton, 2000; Beck, 1993; Borkovec and Ruscio, 2001; Chambless and Ollendick, 2001; Kane et al., 1988; Klerman, 1989; Lambert, 2001; Leon, 1979; Lewinsohn et al., 1998; Marder and May, 1986; Nathan and Gorman, 1998; President’s New Freedom Commission on Mental Health, 2002; Schou, 1997; Shaffer et al., 1996; Trinh et al., 2003; Weston and Morrison, 2001). And health services research investigations have identified correlates to cost-effective and high-quality psychiatric care (Corsico and McGuffin, 2001; Schoenbaum et al., 2001). Accordingly, the current situation can be summarized as follows. Great advances have been made in mental health care in recent years, and technological advances in the basic and clinical neural and behavioral sciences offer considerable promise for future gains. At the same time, the burden of mental illness remains very high, perhaps higher than that of any other single category of disease. Public knowledge about mental illness is increasing, as is public support for continued research. These realities should logically coincide with the growing involvement of psychiatrists in patient-oriented research. Psychiatrists are in a good position to answer relevant etiologic, preventive, and treatment questions about mental illness because they are trained in the biological and psychological basis of such illness, and because they have extensive experience in observing and treating the complexities of a wide variety of moderate to severe behavioral and emotional disorders. The importance of researchers with credentials in psychiatry is predicated on the logic that they have a valuable and unique set of skills and perspectives encompassing the clinical neurosciences, psychopharmacology, psychotherapy, mental illness diagnostics, and integrative human physiology (Andreasen, 2001). These skills place psychiatrists trained in research methods in an excellent position to assess the broad clinical needs of individuals with mental disorders and to frame questions that are relevant to improving patient care. Accordingly, while

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Research Training in Psychiatry Residency: Strategies for Reform a neuroscientist might offer critical information about the importance of a specific neurotransmitter in the pathophysiology that underlies a given brain disease, and a clinical psychologist might effectively measure the associated behavioral symptoms or deliver psychotherapy, it may well be that a psychiatrist is needed to bridge these sophisticated elements to enable the design of a safe and clinically relevant experiment that can yield meaningful insights regarding a novel therapy. For all of these reasons and certainly others, psychiatrists occupy an important and unique niche in the spectrum of neuroscientists and behavioral scientists, and increasing the ranks of psychiatrist-researchers as principal and co-investigators would, in the view of the committee, accelerate advances in mental health. As more objective evidence that psychiatrists contribute to the research enterprise, a recent assessment of published and peer-reviewed literature found that from 1990 to 1998, 16 of the top 22 cited authors of psychiatry articles had been trained as psychiatrists. Included in that assessment were at least 16 of the most reputed psychiatry journals (e.g., Archives of General Psychiatry, British Journal of Psychiatry, Journal of the American Academy of Child and Adolescent Psychiatry) and the multidisciplinary journals Science, Nature, and Proceedings of the National Academy of Sciences. Authors were ranked only if they had published at least 15 high-impact papers during that 8-year period, high-impact being defined as those among the 200 most cited papers during a given year. The most cited psychiatry article during that period was coauthored by a psychiatrist and a non-psychiatrist: Ronald C. Kessler, a sociologist at the University of Michigan,3 and Kenneth S. Kendler, a psychiatrist at Virginia Commonwealth University. These two authors published “Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey” in 1994, in addition to more than 30 other high-impact papers during the 8-year period assessed (ISI Thomson, 2003). Their most cited paper is clearly patient-oriented as it reports on empirically-derived epidemiologic information regarding a number of mental disorders. It also demonstrates the potential productivity that can result from collaborations between psychiatrists and Ph.D. investigators. 3   Currently Professor in the Department of Health Care Policy, Harvard Medical School.

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Research Training in Psychiatry Residency: Strategies for Reform GENESIS OF THE STUDY Trends in Training of Psychiatrist-Researchers NIMH is at the center of U.S. efforts to safeguard mental health and is, accordingly, a principal source of funding for psychiatrist trainees and established researchers. In 2001, NIMH provided more than $230 million in training and research grants to psychiatrist-investigators, and since 1987, well over 60 percent of all extramural grant funding from this institute has gone to either psychiatrist (27–33 percent) or psychologist (36–41 percent) principal investigators (data courtesy of NIMH, Office of Science Policy and Program Policy, February 21, 2003). It is therefore cause for considerable concern that NIMH officials, along with other prominent leaders in psychiatry, believe the training of psychiatrist-researchers is not keeping pace with needs in patient-oriented mental health research (Fenton, 2002; Hyman, 2001; 2002b; Hyman and Fenton, 2003; Kupfer et al., 2002; Shore et al., 2001). This concern stems from data indicating a general decline in physician-researchers across medicine (Ahrens, 1992; Institute of Medicine [IOM], 1994; NIH, 1997b; National Research Council [NRC], 2000; Rosenberg, 2000; Schrier, 1997; Shine, 1998; Wyngaarden, 1979; Zemlo et al., 2000). Data on psychiatrists per se support that contention, although it is not altogether clear whether the numbers of psychiatrist-researchers are declining or simply stagnating at a time when mental health issues have come to the forefront of health concerns in the United States (as discussed above). The extent to which psychiatrist-researchers are needed is also unclear, given that psychologists and other Ph.D. investigators conduct a large and valuable proportion of psychiatric research. Nevertheless, the position of psychiatry appears to be particularly weak with regard to research, and there are data to support that contention. Between 1992 and 2002, the entire NIH budget increased by 55 percent in current dollars, as did the budgets for NIMH and the National Institutes of Neurological Disorders and Stroke (NINDS), Drug Abuse (NIDA), and Alcohol Abuse and Alcoholism (NIAAA)—the four principal institutes that focus on diseases of the brain and behavior. During this same period, the numbers of NIMH-funded psychiatrists as principal investigators kept reasonable pace (see Figure 1-1), although there certainly has been no increase in the relative proportion of psychiatrists in the principal investigator role. If anything there has been a slight decrease, from 33 percent to 27 percent of principal investigators. Similarly, broad surveys of U.S. physicians conducted annually by the

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Research Training in Psychiatry Residency: Strategies for Reform American Medical Association (AMA) indicate that since 1988, the proportion of practicing psychiatrists claiming research as their predominant activity has hovered close to a mere 2 percent (data courtesy of the Association of American Medical Colleges [AAMC], Section for Institutional and Faculty Studies, July 2003). The fact that only 2 percent of practicing psychiatrists spend more than 50 percent of their time engaged in research compares poorly with analogous research involvement rates for several other disciplines of medicine (see Table 1-1), disciplines that are themselves experiencing declining numbers of physician-investigators (Ahrens, 1992; Zemlo et al., 2000). Other direct sources of data on the number of psychiatrist-researchers were difficult to obtain, but at least two sources support the conclusion that research involvement among practicing psychiatrists in the United States and Canada is exceedingly low. Pincus et al. (1993) used 1989 data, collected through a self-report survey, indicating that within academic departments of psychiatry at accredited medical schools, 25.8 percent of non–Ph.D.-holding M.D.’s spent at least 1 day per week engaged in some form of research. For internal medicine, the FIGURE 1-1 Percent of National Institute of Mental Health (NIMH) extramural grants (including research, fellowship, and institutional training grants) stratified by the five major disciplines of the corresponding principal investigators. SOURCE: Data courtesy of NIMH, Office of Science Policy and Program Policy, February 21, 2003.

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Research Training in Psychiatry Residency: Strategies for Reform TABLE 1-1 Research Involvement Rates of Practicing Psychiatrists and Other Selected M.D. Specialists, Years 1999 and 2000 Discipline Research Ratea in 2000 (percent) Research Ratea in 1999 (percent) Number of Active Physicians in 2000 Number Citing Research as Primary Activity in 2000 Number of Active Physicians in 1999 Number Citing Research as Primary Activity in 1999 Psychiatry 2.0 1.9 45,737 913 44,935 870 Neurology 6.3 6.4 12,357 773 11,638 744 Internal Medicine Subspecialtiesb 6.1 6.1 87,114 5,327 85,672 5,264 NOTE: Rates are the proportion of all psychiatrists declaring research as their primary professional activity. aResearch rate = (number of survey respondents citing research as primary activity)/(number of active physicians). bAggregates numbers fromthe following specialties: allergy and immunology, cardiovascular diseases, dermatology, gastroenterology, internal medicine (other, not general), and pulmonary diseases. SOURCE: Pasko and Seidman (2002), AAMC (2002b).

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Research Training in Psychiatry Residency: Strategies for Reform relative proportion of researchers among M.D.’s was nearly twice that, at 41.9 percent. Using more recent data from a 1998 national sample of psychiatrists both within and outside of academic departments of psychiatry, Schwalm (2002a) found that 19.8 percent of responding psychiatrists report some involvement in research (see Chapter 5). Given that this rate of 19.8 includes psychiatrists who spend as little as 1 percent of their time on research, it is logically an overestimate of the proportion of psychiatrists who engage in a meaningful level of research.4 Although these two separate data sources cannot be used to characterize a decline over time, they do indicate that research involvement for psychiatrists have been and continue to be very low. These sources reveal unequivocally that at best only about one in five practicing psychiatrists engages in any research activity, and that if the figures are the same as they were in 1989, only about one in four psychiatrists at U.S. medical schools spends more than 1 day a week adding to the knowledge base of the profession. Finally, and perhaps most disturbing, research training in psychiatry may be on the decline, as indicated by recent surveys of advertised research fellowships for psychiatrists. Fellowships are training periods that typically occur immediately after residency. The American Psychiatric Association (APA) compiles annual lists of research fellowship opportunities for physicians who have just completed their psychiatric residency training. This survey represents a conscientious and high-profile5 attempt by the APA to include all of the research training programs in the United States and Canada at accredited allopathic medical schools—the most logical venues for physician research training programs. Results from the 1992, 1995, and 2001 surveys indicate declines in every category related to research training, including the numbers of institutions, training programs, and M.D.-trained fellows engaged in that training. For example, in 1992 there were 282 M.D.’s recorded in the APA fellowship compilation; in 1995 the number had dropped to 239; and as of 2001 it was at 178 (Guerra and Regier, 2001; Nevin and Pincus, 1992; Steele and Pincus, 1995). Although this survey was not designed as a quantitative assessment of the number of research trainees, the steady decline in their numbers is especially striking, and if it truly reflects a contraction of such programs, it is likely that even fewer new psychiatrists will be pre- 4   Additional analyses provided by Schwalm indicate that less than 3 percent of practicing psychiatrists spend more than 30 percent of their professional time engaged in research. 5   The APA is the largest professional society for psychiatrists in the United States. The most recent version of the survey involved as many as four separate mailings to department chairs and program directors to encourage their response. The APA uses the data collected to promote all the programs by publishing a guide for prospective fellows.

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Research Training in Psychiatry Residency: Strategies for Reform pared for substantive research careers over the next several years (Fenton, 2002). With the above trends in mind, NIMH asked the IOM to conduct a study aimed at determining what factors influence psychiatric residents to consider research careers. Study Charge Given the unparalleled opportunities and needs that exist in mental health research and the apparent decline in the number of psychiatrists entering the research workforce, NIMH commissioned the IOM to address the following four tasks: Review the goals and objectives of training for adult and child psychiatry residents with an emphasis on both core research training and training trajectories to facilitate patient-oriented research career development. This review would provide advice to the Accreditation Council for Graduate Medical Education (ACGME), Residency Review Committee (RRC), and psychiatry community prior to the next cycle of revising residency requirements. Review the experiences of psychiatry residency programs that currently incorporate research and succeed in training successful patient-oriented adult and child psychiatrist researchers. Assess the strategies these programs use and their applicability to other training programs, especially non-research oriented programs. Define new strategies to allow research-training opportunities for psychiatry residents in less research-intensive training settings. Determine obstacles to offering research opportunities to psychiatry residents. These may include access to role models and mentors, economic concerns, and impact of existing training requirements. Consider approaches to overcome these obstacles. Provide strategies for psychiatry residency training that permit research experience and/or more intensive research training tracks while meeting the re-

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Research Training in Psychiatry Residency: Strategies for Reform quirements for clinical competency in adult and child psychiatry. Composition of the Committee To respond to the above charge, the IOM appointed a committee of 12 members broadly representing psychiatry (both adult and child and adolescent from small and large programs), other biological and cognitive–behavioral disciplines (neurology, psychology, neuroscience), mental health economics, and other branches of medicine (pathology and pediatrics). Committee members either were experienced in training biomedical researchers or had direct experience in the field of graduate medical education. The committee included two psychiatry department chairs, a medical school dean, and a director of a children’s hospital research foundation. STUDY APPROACH AND SCOPE Overall Strategy The committee’s work extended over a 16-month period commencing in March 2002. During that period, the committee held five 2-day meetings that included both closed-session deliberations and open sessions for dialogue with experts and stakeholders. The second committee meeting coincided with a full-day public workshop focused on obstacles to research training during psychiatric residency. The committee also gathered information through numerous personal contacts, two commissioned papers, outreach mailings to members of the American Association of Directors of Psychiatric Residency Training, literature reviews, and Internet searches. Appendix A offers additional detail on the study sources and methods. Definitions and Broad Concepts From its deliberations, discussions with NIMH officials, and other sources, the committee formulated the following definitions and concepts that are utilized throughout this report.

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Research Training in Psychiatry Residency: Strategies for Reform Residency as the Focus: One Point on a Continuum Residency is a program of study and clinical training lasting 3 or more years that follows graduation from medical school and precedes certification in a given medical specialty (e.g., psychiatry). Fellowship, by contrast, is 1 or more years of additional training that follows residency. Fellowships usually result in additional certification and/or subspecialization (e.g., addiction psychiatry, research). The study charge directed the committee to study the residency and training trajectories relevant to research career development. The committee believes these trajectories encompass experiences in close proximity to residency training, including those before (e.g., medical school) and after (e.g., fellowship and junior faculty) residency. One notable limitation of this aspect of the study charge is that it does not include later career phases, when previously productive researchers may leave the field because of a lack of funding or a desire to pursue other professional interests and responsibilities (Pincus, 2001b). Nevertheless, the committee believes that evaluation of early career training is a reasonable starting point from which to assess research activity by psychiatrists more broadly. Adult Psychiatry, Subspecialists, and Nonpsychiatrists The study charge directed the committee to consider specifically both adult and child psychiatry residencies. Technically, adult psychiatry residents are nonentities as all psychiatry residents receive marginal child and adolescent training,6 thereby affording them the designation of general psychiatrists. Furthermore, this so-called general training is the foundation upon which other psychiatric training, including the two-year child and adolescent fellowship training, is currently built (Accreditation Council for Graduate Medical Education [ACGME], 2000b). This contrasts child psychiatry training to pediatrics training as the latter is independent from its logical adult-centered counterpart, internal medicine. Accordingly, for simplicity and in keeping with the charge, general psychiatry will heretofore be referred to as adult psychiatry and the child and adolescent fellowship that immediately follows general training will be referred to as a residency. Child psychiatry likely received explicit mention in the study charge because there is broad consensus among mental health professionals that 6   Only 2 months of the 36-month training program in general psychiatry is dedicated to child and adolescent psychiatry.

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Research Training in Psychiatry Residency: Strategies for Reform there is a severe shortage of experts trained to care for children and adolescents with mental disorders (DHHS, 1999; 2000; Kim et al., 2001). Data from NIMH offer some indication of how that shortage may be influencing research participation by child psychiatrists. Although there are seven adult psychiatrists for every child psychiatrist, data from NIMH indicate that from 1993 to 2001, the number of principal investigators in psychiatry favored adult psychiatrist-researchers by a ratio of 11 to 1. Similarly in 2001, of $130 million in R01 grant7 dollars paid to all psychiatrist–principal investigators, only $14 million (less than 11 percent) was paid to child and adolescent psychiatrists.8 The especially low numbers for child psychiatrist–researchers thus support their special consideration in this report on research training. Although this report emphasizes broad psychiatric training by focusing on both adult and child and adolescent training, this emphasis is not intended to minimize the importance of patient-oriented research training for psychiatric subspecialists not explicitly noted in the study charge (i.e., geriatrics, addiction, forensics, pain management). Similarly, this focus is not meant to downplay the psychiatric research contributions and training needs of social and life scientists in other disciplines (e.g., psychologists, neuroscientists) (IOM, 2000). The involvement of psychologists in patient-oriented psychiatric research is, in fact, an important component of psychiatry. Data presented to the committee by Roger Meyer of the Association of American Medical Colleges showed that psychiatry departments are second only to internal medicine departments with regard to their aggregate research budgets (Meyer, 2002; NIH, 2003b). However, it is also the case that well over half of that funding (59 percent) appears to be attributable to the efforts of Ph.D. investigators, whereas in internal medicine and neurology departments, Ph.D.’s make up less than 33 percent of the NIH-funded researchers (Fang and Meyer, 2003). This discrepancy in dependence on Ph.D. research capacity likely is related to the fact that psychology and psychiatry have a uniquely large proportion of intellectual and practical overlap as compared with other academic physicians and their Ph.D. colleagues. The discrepancy also raises the question of whether low numbers of psychiatrist-researchers may be functionally offset by the presence of many capable Ph.D.-credentialed researchers. On the one hand, it is the case that Ph.D.- 7   R01 grants are the most common grant mechanism used by the National Institutes of Health to fund extramural researchers. 8   Raw data courtesy of the NIMH, Office of Science Policy and Program Policy, February 21, 2003. Analysis done by IOM staff.

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Research Training in Psychiatry Residency: Strategies for Reform trained researchers, especially psychologists, play a substantive role in psychiatric patient-oriented research. On the other hand, it is the committee’s belief that psychiatrists bring a unique perspective to that endeavor as trained physicians in the clinical brain and behavior sciences. Accordingly, though not well validated by any hard data, the committee’s opinion is that the study charge is reasonable in its aim to incrementally increase the level of psychiatrist-researchers. Finally, although this goal may appear to favor a “guild” within mental health, its focus on psychiatrists need not represent a “zero sum game” in which having more psychiatrist-researchers corresponds to having fewer psychologists or neuroscientists engaged in that endeavor. Instead, the focus on psychiatrists is aimed at careful analysis of the state of one readily definable sector of the mental health workforce. Patient-Oriented Research According to a 1999 NIH program announcement, patient-oriented research is “…conducted with human subjects (or on material of human origin such as tissues, specimens, and cognitive phenomena) for which an investigator directly interacts with human subjects. This area of research includes: (1) mechanisms of human disease; (2) therapeutic interventions; (3) clinical trials; and (4) the development of new technologies” (NIH, 1999b). Accordingly, the definition is fairly broad and overlaps with that of clinical research, although clinical research does not necessarily require patient interaction. Patient-oriented research also overlaps with translational research, which aims to translate “bench” or more basic research advances into technologies that reduce human suffering from disease. Patient-oriented research does not include basic research that is designed to elucidate the details of normal human or animal physiology. The definition is otherwise fairly broad and includes such efforts as health services research, outcomes research, molecular studies, and epidemiologic studies, as long as they include some data collection directly from human subjects (AAMC, 1999; Association for Patient Oriented Research, 2000; IOM, 1994; Meyer et al., 1998; NIAAA, 2002; National Institute of Child Health and Development [NICHD], 2002; NIH, 1997a; 1997b; NIMH, 2000b).

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Research Training in Psychiatry Residency: Strategies for Reform Limitations of the Data Given that the general problem of the “endangered” physician-investigator emerged nearly 25 years ago (Wyngaarden, 1979), considerable data are available regarding the aggregate of physician-investigators (IOM, 1994; Zemlo et al., 2000); data on subspecialties are more difficult to come by, however. NIMH, for example, provided the committee with some data stratifying the institute’s extramural investigator portfolio by specialty (e.g., psychologist, adult [general] and child and adolescent psychiatrists), but such stratification appears to be new, and thus these data have yet to be carefully scrutinized. Likewise, data on research training approaches are limited in medicine generally and in psychiatry in particular. Accordingly, the committee rarely found well-designed studies in which one group that received a certain type of research training or other exposure was compared with a group that did not. The committee also found that most programs do not carefully track their graduates to determine whether they are researchers, let alone whether they are clinical researchers and to what extent they are engaged and productive in that endeavor. More common in the research training literature and department record keeping is a method of “creaming” for outcome data—that is, describing the success stories and ignoring or downplaying the failures. Such descriptions are used throughout this report and are useful in the face of little other information. Thus, the committee acknowledges that this report is based in large part on its expert judgment, and reliant upon much qualitative and often incomplete data from outside contributors. One important future need identified in this report is for additional tracking and assessment of research training outcomes. ORGANIZATION OF THE REPORT The remainder of this report is organized into five chapters. Chapter 2 develops a rationale for residency as a target of patient-oriented research training. In that chapter, residency is placed in the context of a broader career continuum that includes medical school and fellowship training. The chapter begins by describing the benefits of incorporating research training into residency. It then addresses the importance of linking research training in residency to research exposures before (e.g., medical school) and after (e.g., fellowship) that time. The chapter concludes with some general themes regarding long-term training and a brief description of training models outside of psychiatry.

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Research Training in Psychiatry Residency: Strategies for Reform Chapters 3 through 5 address in turn the following three major sets of factors that influence research training: regulatory, institutional, and personal. More specifically, Chapter 3 reviews regulatory issues and, per item 1 of the committee’s charge, is focused in particular on the Residency Review Committee program requirements for psychiatry and other residencies, which must be met by all programs wishing to be accredited to train medical specialists, including psychiatrists. This chapter also briefly describes the role of the American Board of Psychiatry and Neurology and several other organizations and professional societies with regard to residency-based research training. Chapter 4 examines institutional issues related to research training within a department of psychiatry and more broadly within the individual hospitals or universities. The chapter begins by describing the idiosyncrasies and challenges associated with the funding of graduate medical education, and then turns to leadership and mentoring issues. The chapter concludes with a review of local and national program strategies (e.g., curricula) currently being used to train clinical researchers within and outside of psychiatry. Chapter 5 moves from the extrinsic factors reviewed in Chapters 3 and 4 to the more intrinsic or personal factors that influence research training in the context of the psychiatric residency. Motivation and intellectual capacity are briefly discussed as a reminder that certain factors transcend programmatic structure or resources. Personal finances, including debt and training stipends, are also addressed in this chapter. Finally, issues of race and gender are discussed, as are the unique issues faced by foreign medical school graduates. At the close of Chapters 2 through 5, the committee offers recommendations corresponding to the respective topics. A final Chapter 6 offers some future directions for action beyond the recommendations cast in Chapters 2 through 5. That chapter also addresses the need for better data to characterize the psychiatrist-researcher workforce and the effectiveness of individual and national training programs. The report ends with four appendices. Appendix A describes the methods used for this study and the open-session meetings and public workshops hosted by the committee. Appendix B lists funding opportunities for individuals and programs interested in developing their research training portfolios. Appendix C provides brief programmatic characteristics of selected residency training programs. Finally, Appendix D contains biographical sketches of committee members and study staff.

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