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Residency as Part of a Longitudinal Career Continuum

The previous chapter detailed the need for and apparent shortfall in the number of psychiatrist-researchers. This chapter places residency in the broad longitudinal continuum of physician training, ranging from the undergraduate years, to medical school, residency, fellowship, and beyond. It begins by examining why residency is a critical juncture for career planning and at least some research training. It then describes the importance of research training and exposure before and after residency, as well as how such training and exposure are implemented in psychiatry, internal medicine, and pediatrics. Strategic considerations involved in providing an integrated, longitudinal research experience are addressed, and brief descriptions of existing mechanisms for serving this purpose are presented. The chapter ends with conclusions and a single recommendation regarding longitudinal research training associated with residency.

RESIDENCY AS AN IMPORTANT TARGET FOR RESEARCH TRAINING

Residency is the last obligatory stage of preprofessional education for most psychiatrists (see Figure 2-1). Therefore, career differentiation occurs for many psychiatrists during this experience, which can be considered an essential node that connects medical school to one of several possible long-term career paths. Thus it makes sense to examine activi-



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Research Training in Psychiatry Residency: Strategies for Reform 2 Residency as Part of a Longitudinal Career Continuum The previous chapter detailed the need for and apparent shortfall in the number of psychiatrist-researchers. This chapter places residency in the broad longitudinal continuum of physician training, ranging from the undergraduate years, to medical school, residency, fellowship, and beyond. It begins by examining why residency is a critical juncture for career planning and at least some research training. It then describes the importance of research training and exposure before and after residency, as well as how such training and exposure are implemented in psychiatry, internal medicine, and pediatrics. Strategic considerations involved in providing an integrated, longitudinal research experience are addressed, and brief descriptions of existing mechanisms for serving this purpose are presented. The chapter ends with conclusions and a single recommendation regarding longitudinal research training associated with residency. RESIDENCY AS AN IMPORTANT TARGET FOR RESEARCH TRAINING Residency is the last obligatory stage of preprofessional education for most psychiatrists (see Figure 2-1). Therefore, career differentiation occurs for many psychiatrists during this experience, which can be considered an essential node that connects medical school to one of several possible long-term career paths. Thus it makes sense to examine activi-

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Research Training in Psychiatry Residency: Strategies for Reform ties and other influences within residency that encourage or inhibit research career tracking. The rationale for focusing on research training during residency must be clearly stated to justify the allocation of resources (e.g., time, funding) needed to increase residency research options. Several logical arguments are advanced below and are summarized in Box 2-1. FIGURE 2-1 Training pathways in psychiatry. BOX 2-1 Rationale for Incorporating Research Training into the Residency Experience Promotes research literacy for all trainees. Encourages future participation of clinicians as research collaborators. Provides experiences that may foster choosing a research career. Couples expanding clinical knowledge with the formulation of patient-oriented research questions. Attracts the curious and/or motivates medical students to psychiatry training. Maintains and furthers research interest among residents with investigative backgrounds.

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Research Training in Psychiatry Residency: Strategies for Reform Research Literacy Research didactic learning or practical experiences in residency have the potential to promote research literacy—the ability to assimilate emerging theoretical knowledge about biology and empirical information relevant to a given set of symptoms and corresponding risk factors or treatments. Being research literate also means having the knowledge and ability to understand and convey to peers and patients the challenges that exist to the development of new knowledge. Accordingly, the ability to read the literature critically is important, as is an appreciation for the difficulty of creating, implementing, and interpreting an experimental protocol. Stated another way, research literacy can be considered a prerequisite for the lifelong practice of evidence-based medicine that involves “explicit and judicious use of current best evidence” to care for patients (Sackett et al., 1996:71). Findings of surveys of psychiatry trainees and faculty appear to validate the notion that integration of research into residency enhances residents’ ability to care for patients (Fitz-Gerald et al., 2001). Research literacy is particularly important given the quantity and variety of medical information that is routinely published and presented (Mulrow and Lohr, 2001). Moreover, research literacy may encourage research collaboration on the part of those who will spend a majority of their professional time in clinical care, providing clinical psychiatrists with the skills needed to serve knowledgeably as coinvestigators for research studies focused on psychiatric disease or for studies in which psychiatric comorbidity is important to overall patient health (e.g., depression in cancer patients). For example, increased appreciation of research may eliminate some of the barriers to subject recruitment that can result from misunderstanding of research protocols on the part of physicians or patients. Well-informed clinicians can help potential research subjects understand the limitations of a given research protocol, including the interpretation and practical use of clinical data that result from participation in the research. The concept of and need for a randomized and double-blind design may otherwise be unclear, even antithetical, to many patients. Research literate physicians also will be more equipped to characterize the uncertainties (e.g., probability, relative risk) of disease course or treatment outcomes to patients, and to do so using information that is constantly being updated by the latest technologies and scientific findings. In summary, although much of medicine, including psychiatry, has a considerable evidence base supporting practice methods, the committee’s strong sense is that residency-based exposure to research theory and

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Research Training in Psychiatry Residency: Strategies for Reform practice can have a very positive effect on strengthening the evolution and implementation of the best psychiatric practices. Additionally, and most germane to this report, such exposure should encourage more psychiatrists to devote at least a portion of their professional training and time to research. Exposures and Experiences As suggested above, residency is a time of critical career decision making. If too few psychiatry trainees opt for research-intensive careers, the reasons may lie, at least in part, within the residency experience (Appelbaum et al., 1978; DeHaven et al., 1998). Exposure to research theory and practice in residency has not been assessed as frequently as such training in the context of postresidency fellowship, but there is some evidence that residency-based research training is an antecedent to future research career tracking, albeit from other disciplines. For example, a recent survey of 96 surgical residency graduates from the University of California at Los Angeles (a 65 percent response rate) demonstrated that those with at least 2 years of residency-based research laboratory experience were twice as likely as those with less training to track to an academic position (Dunn et al., 1998). DeHaven and colleagues (1998) conducted a broad telephone survey (n = 321) of family medicine residency programs (a 75 percent response rate), followed by a more targeted survey (n = 72) of recent graduates and training directors and in-depth interviews with 28 of the most research-intensive residency programs. They found that interest in practice-based research coincided with training programs in which a majority of residents had completed a research project, and in which there were opportunities for research that included program director support and a research curriculum. Correlative studies examining the impact of fellowship training have been conducted in psychiatry as well as in other medical specialties (Davis and Kelley, 1982; Dial et al., 1990; Dunn et al., 1998; Haviland et al., 1987; Pincus et al., 1993; Ringel et al., 2001). Pincus and colleagues (1995) conducted a survey of 1,917 M.D. faculty members in departments of psychiatry from 116 U.S. medical schools. Using a fairly precise and inclusive definition of a “researcher” (i.e., only 20 percent of one’s time engaged in research activities), they found that M.D.’s with postdoctoral research training were 4 times more likely to be researchers than their colleagues without such additional training. Lee and colleagues (1991) surveyed 2,642 clinical researchers (2,487 with MD degrees) and found that 1,371 of them had received federal research funding. Multi-

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Research Training in Psychiatry Residency: Strategies for Reform variate analysis further found that research training during fellowship in this sample of clinical researchers was a positive predictor of such funding. The above studies clearly identify early career research training as a correlate to research activity later in life, although the support for residency-based research training is less common and less well documented than that for fellowship training. In fact, Davis and Kelley (1982) surveyed over 500 M.D. clinical investigators across specialties and found that 66 percent had decided on a research career before completing residency. Additionally, Davis and Kelley found that among 171 respondents who recalled “a particular person or event” as being influential in their career decision, only 11 percent experienced that influence during residency, with 40 percent doing so in medical school and 35 percent after residency. One interpretation of these numbers is that residency is not an important point at which to engage a would-be physician in research training. However, it is equally plausible that the dip reported in residency is the result of the intense clinical demands that occur at that stage, combined with a status quo in residency curriculum that typically involves little research training. From this perspective, residency may represent an untapped opportunity to integrate more research training during a time when career decisions have yet to be completely formed. Accordingly, it appears reasonable to conclude that if fellowship training encourages research career tracking, slightly earlier training might enhance that process, and would be most effective if it simultaneously encouraged residents to pursue research fellowships. In support of that contention, Neinstein and MacKenzie (1989) found that in a survey of 772 academic physicians, 87 percent had received fellowship research training, and more than 50 percent had received research training during residency and even during medical school. Given the strong linkage found between residency and fellowship research training and the fact that so many who received such training became academicians, early training appears to be an important precursor to a research career. What the study does not conclusively demonstrate is whether these individuals would have gone on to pursue research fellowships in the absence of such early training, nor does it rule out the possibility that fellowship and not residency training is the key factor in predicting an academic career (an issue discussed later in this chapter). Insufficient data exist to judge whether residency-based research training before a fellowship experience makes a significant difference. Nonetheless, it is the strong sense of the committee that the earlier research training occurs the better, and that such training can complement and form a key portion of requisite clinical training because research training (espe-

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Research Training in Psychiatry Residency: Strategies for Reform cially in patient-oriented research) is so closely linked to the practice of evidence-based medicine. Opportunities to Formulate Patient-Oriented Research Questions Patient-oriented research requires an understanding of the current strengths and weaknesses of clinical care and of emerging technologies that might be used to take that care to a higher level of quality and efficiency. Thus for most psychiatry trainees, residency may be their first opportunity to formulate substantive patient-oriented research questions. Earlier research experiences (e.g., in medical school), especially those that pertain to patient-oriented research, are likely to be less productive for at least two reasons. First, medical students are likely not to have the academic (scientific or clinical) knowledge that residents possess, and thus are less intellectually equipped to formulate contemporary and testable hypotheses. Second, medical students have not served as the primary medical provider to a large number of patients. Such direct patient interactions and responsibilities logically can inspire research questions in the minds of residents, and can also give them a real-world view of the potential impact of advances in patient-oriented research. Attracting and Sustaining the Interest of Talented Medical Students Residency training programs that offer research experiences will likely attract medical students with the greatest interest in and ability to pursue research careers. Such students will likely include M.D./Ph.D.’s or equivalently prepared trainees, who traditionally have chosen the more research-intensive specialties, such as internal medicine (Institute of Medicine [IOM], 1994) and neurology (see the discussion of intellectual capacity and scientific orientation in Chapter 5). Once research-oriented residents have been recruited into psychiatry, it is imperative that they maintain their investigative interests and research skills during the 4- to 5-year residency. The absence of any research experience and lack of exposure to those regularly conducting research during this long period can effectively extinguish any earlier predilection toward such endeavors. This is especially true for M.D./Ph.D. trainees, as research training in a Ph.D. program is typically followed by up to 6 years of clinical training (i.e., medical school and residency) before trainees have the opportunity to reenter research through a fellowship or academic faculty position. Fostering the recruit-

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Research Training in Psychiatry Residency: Strategies for Reform ment and engagement of individuals with an M.D./Ph.D. is important to psychiatric research, as these dual-degree researchers hold 20 to 30 percent of all National Institutes of Health (NIH) grants awarded to physician-scientists, even though they account for less than 2.5 percent of medical school graduates (Association of American Medical Colleges [AAMC], 2002a; Ley and Rosenberg, 2002; Zemlo et al., 2000). Although the committee can cite no empirical data to support the importance of maintaining research skills and interest through inclusion of research experiences in residency, it appears logical that such training would be both practical and encouraging. It furthermore appears that patient-oriented research training would serve to keep the trainee abreast of new methodologies and important discoveries entirely germane to competent clinical practice. IMPORTANCE OF LONGITUDINAL TRAINING FOR POTENTIAL RESEARCHERS Residency is the committee’s focus, but experiences before and after that period are integral and extremely important parts of the entire clinical research training endeavor. Preresidency training (i.e., undergraduate, medical school) and postresidency experiences (i.e., fellowship and junior faculty status) both have a substantial influence on the number of young psychiatrists who choose to engage in patient-oriented research. While residency clearly constitutes a key crossroads in the career path of many M.D.’s, it represents but one step toward a research career. It is widely acknowledged that more than 2 years of uninterrupted research training is necessary to launch the career of a successful physician-researcher (IOM, 1994; Kimball and Bennett, 1994; Kupfer et al., 2002; Pincus et al., 1995). Given the time that residents must devote to the mastery of clinical skills, research experiences in residency will thus likely provide only a small portion of the overall research training necessary to prepare competent patient-oriented investigators. Accordingly, residency-based research experiences will be most effective if linked to pre- and especially postresidency (i.e., fellowship) training to create an integrated, longitudinal, and thorough research training experience.

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Research Training in Psychiatry Residency: Strategies for Reform Preresidency Experiences Research experiences during undergraduate education and medical school may shape career preferences. Rancurello (1988) suggests that medical schools that provide a strong psychiatry teaching curriculum, engaging instructors, and training in evidence-based medicine are likely to increase the pool of talented medical students who will be interested in psychiatric research. There are a number of avenues, both formal and informal, through which preresidency trainees can obtain research exposure. Informal Research Experiences Undergraduate and, for medical students, preclinical summer research opportunities in psychiatry departments can foster long-term interests among students majoring in related disciplines (e.g., neuroscience, psychology). Medical students may be inspired, alternatively or additionally, to pursue a psychiatric career by the psychiatry clerkship that typically occurs in the third year of medical school (Sierles and Taylor, 1995). The perception that medical school experiences have an impact on future career choices is strongly supported by the findings of a survey of medical students indicating that approximately 80 percent changed their specialty preference after entering medical school (Kassebaum and Szenas, 1995). An analysis of data from a survey of nearly 500 post– medical school graduates declaring psychiatry as their specialty examined what factors predicted outcomes corresponding to research fellowship and eventual research career plans. Although the magnitude of individual effects is difficult to derive from this analysis, it is apparent that research involvement (as author or investigator) and a research-intensive environment during medical school both were strongly correlated with a new psychiatric resident’s desire to pursue a research fellowship and a longer-term research career (Haviland et al., 1987). This study points to the importance of direct and more subtle (e.g., medical school culture) influences on a trainee’s career intentions. Recognizing the importance of recruiting medical students, the disciplines of both internal medicine and neurology have developed student interest groups (i.e., social groups) to educate and attract medical students to their respective specialties (Albritton and Fincher, 1997). Robert Griggs, chair of the Neurology Department, University of Rochester, and

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Research Training in Psychiatry Residency: Strategies for Reform editor of Neurology, told the committee that such groups not only are inexpensive to run, but also have been important in maintaining a general and a researcher pipeline of neurology students. Several such medical student interest groups also exist in departments of psychiatry, but it is not known how frequently they are used or how successful they are at attracting undergraduates to careers in psychiatric research. Formal Research Experiences Formal education programs also exist that support research training in the college or medical school years. The NIH R25 grant mechanism provides funding of up to $150,000 a year over 3 to 5 years for the development of research training curriculum. The University of Pittsburgh (Western Psychiatric Institute and Clinic [WPIC]) and Yale University have both received R25 grants from the National Institute of Mental Health (NIMH). The WPIC program, in collaboration with Carnegie Mellon University, began offering an undergraduate research fellowship in 1994 (Grant No. 5R25MH054318-07). The program selects outstanding junior and senior college students with an interest in postbaccalaureate training in mental health. They are given a small stipend and partial tuition support (WPIC, 2002b). Participants in the year-long program develop a research proposal and conduct supervised clinical or basic research. Trainees also attend two semester-long courses on clinical psychiatry and the neurological bases of psychiatric disorders and participate in a month-long clinical rotation. Participants engage as well in a 14-week-long summer program at WPIC, during which they meet investigators, attend lectures, and visit laboratories. The program enables trainees to obtain in-depth experience in both clinical and basic research in mental health while receiving undergraduate degrees in the neurosciences and the biological, chemical, and psychological sciences. Outcome data from 1994 to 1999 for 65 of 83 trainees indicate that the vast majority (88 percent) received postbaccalaureate training in the health sciences (receiving mainly an M.D. or a Ph.D. in the neurosciences or psychology), and 56 percent published research results within 3 years of completing the program (personal communication, G. Haas, WPIC, April 18, 2003). The Yale program targets medical students interested in neuroscience research training (Grant No. 5R25MH060477-04). This program, which began in 1999, has a didactic component that again integrates both basic and clinical neuroscience concepts, with case reports, including

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Research Training in Psychiatry Residency: Strategies for Reform live patient interviews. Selected students may further take part in a year-long mentored research experience, which also provides considerable time and support to trainees in developing an individual research project (NIH, 1999a). Dual-degree programs are increasingly being used to provide medical students and others with formal research training. As of 2002, 37 institutions offered M.D./M.P.H. degrees (AAMC, 2002d). Other programs offer different masters degrees. Wayne State University, for example, offers a master of science in psychiatry to medical students, residents, and fellows; completion of the degree requires supervised research work and a thesis defense (Balon and Kuhn, 2001). Medical students who participate take a year off from their medical schooling. They are funded through a combination of department and senior investigator funds. Since the mid-1990s, three medical students have participated in the program, and all have been first authors of articles and abstracts, made national presentations, and moved on to research-oriented residency training programs; two have attended the American Psychiatric Association’s (APA) Research Colloquium (Balon and Kuhn, 2001). The Medical Scientist Training Program (MSTP) also provides a formal mechanism for research-oriented trainees. Started in 1964, the NIH-funded program provides M.D./Ph.D. trainees with extensive training in laboratory and clinical research over a 7- to 8-year period (AAMC, 1999). M.D./Ph.D. students in the neurosciences are attractive candidates for psychiatry residency and research career tracking (Rancurello, 1988). A web-based review of 13 MSTPs revealed that of 1,133 graduates, 57 (or 5 percent) pursued a residency in psychiatry or received an academic appointment in a psychiatry department.9 Given that psychiatrists represent approximately 5 percent of all physicians (AAMC, 2002b), it would appear that psychiatry does a reasonable job attracting M.D./Ph.D. students in comparison with other branches of medicine. Nevertheless, increasing the proportion of MSTP graduates entering psychiatry training could have a profound effect on the future of psychiatric research, especially if these new M.D./Ph.D. graduates could be tracked in higher numbers to patient-oriented research careers. Accomplishing this will be challenging, however, since many M.D./Ph.D. trainees pursue basic research careers (AAMC, 1999; Ahrens, 1992; Frieden and Fox, 1991; Sut- 9   Data obtained from the following institutions as of December 20, 2002: University of California, Irvine; University of California, San Diego; Yale University; University of Iowa; University of Michigan; Washington University; Albert Einstein College; Duke University; Case Western Reserve University; Medical University of South Carolina; Baylor College of Medicine; University of Texas Southwestern Medical Center at Dallas; University of Virginia Health System; and Medical College of Wisconsin.

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Research Training in Psychiatry Residency: Strategies for Reform ton and Killian, 1996), while others elect to not continue their research careers after entering the clinical phase of their training. While the federal government funds a number of initiatives, including the R25 mechanism and the MSTP, foundations also fund preresidency research training. The recently established Doris Duke Clinical Research Fellowship Program offers high-achieving medical students a year of clinical research. Medical students receive a $20,000 stipend, and mentors are given a small stipend for their efforts. The program is administered by 10 selected universities, each of which houses at least 5 fellows. Of the 106 fellows during 2001 and 2002, 15 were involved in neuroscience and 6 in psychiatry. Appendix B lists other funding opportunities for individuals and programs interested in developing their research training portfolios (the appendix is organized by career stage and is designed to be illustrative rather than exhaustive). Postresidency Experiences Residency is very rigorous, leaving limited opportunity to engage in patient-oriented research. This is particularly true for residents who receive clinical subspecialty fellowship training. Research training is usually not integrated with child and adolescent psychiatry training or with postresidency fellowship training in geriatric, addiction, forensic, and consultation-liaison psychiatry (Pincus et al., 1995). Training in child and adolescent psychiatry, for instance, typically requires a 5-year residency (3 years of adult [general] psychiatry and 2 years of subspecialty training in child and adolescent psychiatry) and is clinically intensive, and most programs allocate only about 4 months for elective activities (see the discussion of the Psychiatry Residency Review Committee in Chapter 3). While some new psychiatrists can move directly from residency to academic positions, most who wish to become independent researchers enroll in additional training. Indeed, further preparation for research careers (in the form of a fellowship) is usually essential for individuals who wish to conduct independent psychiatric research. As noted earlier in this chapter, Pincus et al. (1995) found a significant, positive correlation between fellowship training and psychiatric research career involvement among M.D.’s. They also found a “dose-response” association of sorts, as the length of that training was positively correlated with subsequent research involvement for all single-degree doctorate holders (i.e., M.D. or Ph.D. alone, but not M.D./Ph.D.). Using a survey of 117 (78 percent response rate) early- to mid-career pediatricians with a track record of

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Research Training in Psychiatry Residency: Strategies for Reform Private Funding Mechanisms Private foundations and professional societies offer a number of research fellowships in psychiatric research. Two exemplary research training fellowships for psychiatrists are the National Alliance for Research on Schizophrenia and Depression’s (NARSAD) Young Investigator Award and The Robert Wood Johnson Foundation’s Clinical Scholars Program. NARSAD’s award provides up to $30,000 for 1 to 2 years for fellows and junior faculty to conduct research pertaining to major mental disorders, including schizophrenia and affective disorders. NARSAD funded 175 junior investigator awards in 2003 (NARSAD, 2002; 2003). The program of The Robert Wood Johnson Foundation is aimed at young physicians who are committed to medicine and are interested in the acquisition of new skills and training in the nonbiological sciences important to medical care systems, including epidemiology and health services research. The 2-year fellowship is supported by a stipend of about $44,000 and requires the completion of graduate-level work, with up to 20 percent of a fellow’s time being devoted to maintaining clinical skills. Fellows in the program reside at one of seven universities, each with its own priority area (e.g., evaluating health care practices and interventions at The Johns Hopkins University, or improving the care of America’s at-risk populations at the University of California, Los Angeles). Former scholars are involved in academic (60 percent) and clinical (13 percent) medicine or public policy. As of July 2002, nearly 900 scholars, including more than 80 psychiatrists, had completed the program (The Robert Wood Johnson Foundation, 2001). A small number of fellowships supported by the pharmaceutical industry are coordinated by professional societies, such as the APA’s American Psychiatric Institute of Research and Education (APIRE) and the American College of Neuropsychopharmacology. Additionally, since 1989 the APA has administered the T32-supported Program for Minority Research Training in Psychiatry, which funds research experiences from medical school through postresidency fellowships (see the discussion of underrepresented racial and ethnic minorities in Chapter 5). Residents may pursue various areas of investigation, including schizophrenia, neuroscience, and child psychiatry (APA, 2002d). As of 2002, 45 of the 58 graduates of this T32 program held an academic or research position, had received 109 grants/awards, and had authored more than 400 journal articles and books. Of the remaining 13 graduates, who are affiliated primarily with a private practice, many have published articles or received grants (personal communication, E. Guerra, APA, December 4, 2002).

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Research Training in Psychiatry Residency: Strategies for Reform APIRE also collaborates with pharmaceutical companies. For instance, APIRE and Eli Lilly sponsor a 1-year fellowship for trainees who have completed their psychiatric residency. Initiated in 1988, the award provides a $45,000 stipend, and fellows are required to spend 85 percent of their time doing research (APA, 2002a). APIRE also collaborates with Wyeth Pharmaceuticals, Janssen Pharmaceuticals, and GlaxoSmithKline to fund similar fellowships. In fact, of the 12 APA awards listed on the APIRE website, all but 2 are funded in part by pharmaceutical companies (see Appendix B for further description of funding opportunities available through professional societies). Despite the availability and successes of research fellowship programs, such programs often are not utilized (Kimball, 1994; Whitcomb and Walter, 2000; Zemlo et al., 2000). For instance, Whitcomb and Walter (2000) found that only 2 percent of subspecialty fellows entered the research-oriented American Board of Internal Medicine (ABIM) pathway (discussed further below), despite efforts to enroll as many as 10 percent of such fellows. Likewise, Zemlo et al. (2000) found that physicians do not track to additional fellowship training, in part because of lengthened training in preparation for a research career and limited stipends. Low financial compensation no doubt offers some explanation for why residents do not pursue fellowships in increasing numbers. Fellowships add time to training, and they do so while offering salaries below what clinicians with the same experience earn. Specifically, the average fellowship stipend is $40,000 to $50,000, whereas clinical salaries are double or triple that amount.10 Given this financial disincentive to engage in research training, it is especially important that fellowship experiences be linked practically and conceptually to residency. Practical linkage means appropriate financial aid to those who qualify; conceptual linkage means demonstrating to the resident that there is light at the end of the tunnel in the form of junior and senior research career awards (see below) that can offset the short-term sacrifices in salary (see Chapter 5 for a discussion of personal finances). Early Mentored Career Awards Beyond fellowship, or even in the late stages of fellowship, potential psychiatrist-investigators can benefit greatly from early mentored career 10   The average entry-level salary for a psychiatrist in New York State was $120,000 in 2001 (Nolan et al., 2002); nationally, the mean salary for psychiatrists in 2001 was $114,000 (Bureau of Labor Statistics, 2002).

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Research Training in Psychiatry Residency: Strategies for Reform awards (K awards). This NIH funding mechanism provides salary support to a maximum of $90,000 per year for up to 5 years. Under the supervision of a designated mentor, awardees are expected to commit 75 percent of their time to a research project, and they are provided protected time to acquire skills and conduct their own research, which leads them to achieve the status of independent investigator. One of the long-term goals of K awardees is to progress to principal investigator status on research grants such as NIH R01’s. NIMH recently reviewed the achievements of 241 K awardees who received funding between 1989 and 2000, including active (n = 163) and completed (n = 78) grants (personal communication, A. Permell and W. Goldschmidts, NIMH, December 12, 2002). Of these awardees, 119 had applied for an R01 grant, and 62 (52 percent) had been funded. A separate review of 31 early research career awardees (K awards and the discontinued R29 or “FIRST” award) in geriatric/aging mental health research was recently conducted using the public Computer Retrieval of Information on Scientific Projects (CRISP) database (Bruce, 2002). More than 40 percent of individuals who had completed their early career awards between 1997 and 2001 had obtained R01 grants. Given that success rates for psychiatrists on K awards in recent years have been at least 40 percent—similar to those for other mental health professionals, such as psychologists11—an ambitious psychiatrist can consider the path from K award to R01 an attainable career goal. At the same time, it is reasonable to ask why as many as 60 percent of K awardees do not appear to move to the next level of the federal grant pipeline. Some certainly carry on their research as coinvestigators or as investigators on foundation- or industry-sponsored projects, so that the 60 percent “failure” rate for K awardees is likely overestimated. Others, however, simply do not go on to become productive researchers. Given that a 5-year K award involves a federal investment that can easily exceed $500,000 per awardee, it is imperative that studies be done to understand why the failure rate in mentored research training is so high. One potentially useful way to conduct such studies would be to survey the trainees and mentors who fail at the intended transition of K award to R01, and compare their experiences and attributes with those of the individuals who succeed. 11   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 IOM outreach to K awardees. To understand some of the concerns of today’s K awardees, the committee interviewed seven randomly selected12 psychiatrist-investigators who had received K awards since 1998 (see Appendix B). Not surprisingly, interviewees noted that limited time and money were their two chief concerns. One respondent complained that research time is often taken up by administrative and clinical responsibilities, leaving little time to read, think, and write. Nearly all respondents noted limited protected time for research, low salaries relative to those of full-time clinicians, and general uncertainty about continued funding. Good mentoring, hard work, a supportive spouse/partner and/or department chair, and a strong interest in research and writing were factors commonly cited as helping to overcome the obstacles to a research career. Unfortunately, the confidentiality requirements of NIMH prevented the committee from making parallel inquiries of individuals whose K applications had not been approved and who had chosen not to resubmit or further pursue a career development award. Consequently, it is not clear what factors, personal or professional, prevented them from obtaining federal funding. AAMC and NIH outreach to K23 awardees. The K23 is a relatively new NIH award, designed specifically to offer mentored training for patient-oriented researchers. For strategic planning purposes, AAMC and NIH hired a market research firm to conduct three focus groups with approximately 30 awardees in March 2001. The results obtained from those focus groups were very similar to those of the outreach described above. The K23 recipients were concerned principally about time and money. Time limitations were imposed largely by clinical demands, although some frustration with regulations related to clinical research (e.g., protection of human subjects) was also noted. Academic institutions were characterized as interested in research, but not forthcoming with support in the form of resources and true protected time for funded or intramural research efforts. Although protected time was a central theme among these respondents, it is interesting that they did not suggest that their departments or institutions needed to be more respectful of their 75 percent protected time (a requirement of the K23 award). Instead, they recommended that a K23 award be available that would cover 50 percent research time so awardees could spend the remaining 50 percent on clinical work. Although most respondents were enthusiastic about submitting 12   K award recipients in psychiatry were identified using the federal CRISP database (NIH, 1999a) and randomly selected from that list.

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Research Training in Psychiatry Residency: Strategies for Reform future applications for federal grants, especially R01 grants, most also expressed the need for additional bridge funding between the K23 and a large independent research grant. Details of this bridge and the reason it would be necessary after 5 years of training support, however, were not explored (Henderson et al., 2001). Despite these limitations, the K23 was noted as a good jump-start for a clinical research career. Focus groups were not conducted with individuals whose K awards had not been funded and who had chosen not to pursue further resubmission. STRATEGIC CONSIDERATIONS Early planning can allow for useful connectivity between residency and fellowship, and then to career awards. In particular, those interested in research-intensive careers should consider research fellowship training as early as possible during residency, since, as noted previously, early research experiences are known to be correlated with research career tracking (Davis and Kelley, 1982; Dial et al., 1990; Dunn et al., 1998; Haviland et al., 1987; Pincus et al., 1993; Ringel et al., 2001). Opportunities for residents to participate in research and to continue such endeavors into fellowship in the same department have the advantage of providing a more cohesive longitudinal research training period—one that is often preferable to two or more fragmented research training periods. The utility of this approach is supported by the reality that the best residents are encouraged to remain as fellows in the departments in which they have trained. Given the clinical responsibilities and goals of residency, most programs offer few if any direct research experiences to the large majority of residents (see the discussion of program and curriculum structure in Chapter 4). Accordingly, research fellowship training is often the first concentrated and practical research experience encountered by a psychiatrist. It is also one that can provide a realistic transition to junior faculty status. This multistep career path will likely not be obvious to trainees themselves, who are preoccupied with the academic, clinical, and core paperwork demands that must be met to transition from one training phase to the next. Therefore, some programs have developed and promoted a departmental culture aimed at funding research training at all career stages. For example, WPIC has created a portfolio of grants and discretionary funds to ensure that research training is supported at all educational stages, including the requirement that a large number of faculty have senior career or independent research awards (Pincus, 2002;

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Research Training in Psychiatry Residency: Strategies for Reform Pincus et al., 1993) (see Table 2-1). Given WPIC’s success (it receives the highest level of NIH funding among psychiatry departments13), the development of similar multilayered grant portfolios should be attempted by other programs. Even if such a multistage strategy can be implemented only on a small scale (e.g., one or two funded slots at each career stage), it has the potential to familiarize both institutions and trainees with the fullest range of funding options across the research workforce pipeline. Models from Outside of Psychiatry Although pediatrics and internal medicine have far from solved their own problems of attracting residents to research careers, these two disciplines have created pathways that link residency training with 2- or 3-year research-intensive fellowships. The connection is made by offering TABLE 2-1 Western Psychiatric Institute and Clinic’s Developmental Pathway for Psychiatric Researchers Duration of Training (years) Stage of Education Funding Mechanisma 4 Undergraduate R25 research grant 4 Medical school T32 training grant, Medical Scientist Training Program 4 Residency Research track (department funded) 2 Fellowship T32 training grant 2 Junior faculty (1) R25 research grant 5 Junior faculty (2) Career (K) award -- Senior faculty Career (K) award, Research (R) grant, Project (P) grant NOTE: a National Institutes of Health unless otherwise noted. SOURCE: Pincus (2002) 13   Nearly $78 million in fiscal year 2002.

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Research Training in Psychiatry Residency: Strategies for Reform residents the opportunity to shorten their general residency training by 12 months if they commit to extra research and subspecialty training of 2 to 4 years. The ABIM research pathway, known as the Clinical Investigator Pathway (CIP), requires that enrolled fellows spend 80 percent of their time engaged in research training, leaving the other 20 percent for clinical service (ABIM, 2002). A review of two institutions that offered a CIP—Brigham Young University and Massachusetts General Hospital—indicates that more than 75 percent of program graduates remained in research careers (Kimball, 1994). A more recent review, however, notes two significant problems with the program. First, despite the mandate for 80 percent research time, fellows, even at academic centers, typically are able to devote only 50 percent of their time to research because of their institution’s clinical demands. Second, and more disturbing, it appears that this program is recruiting trainees at rates far below those projected—2 percent rather than 10 percent of all subspecialty fellows (Whitcomb and Walter, 2000). These realities suggest that the incentives associated with the pathway are not keeping pace with clinical revenue and other pressures steering trainees away from research careers. For pediatrics, research training has been combined with subspecialty training (i.e., not available to general pediatrics residents) (American Board of Pediatrics [ABP], 2001; 2002a; 2002b). Additionally, ABP recently approved several pathways—including the Integrated Research Pathway and the Subspecialty Fast Track Pathway—that allow early integration of research into residency for those with previous research experience (e.g., M.D./Ph.D. degree holders), as well as the Special Alternative Pathway, for those who achieve clinical competency at an accelerated pace. Most of these pathways offer some time incentive to trainees such that if they commit to research training, they can complete some of the core training requirements in less time or engage in research training earlier than standard pathway residents. Table 2-2 summarizes these pathways, along with the previously established Pediatric Scientist Development Program (PSDP). All, with the exception of the PSDP, are too new for any outcome information to be available. The PSDP is a 6- to 7-year pathway that adds 3 to 4 years of research fellowship onto standard residency training. It also offers trainees the possibility of assuming a junior faculty position once they graduate. A 2002 review of 89 PSDP fellows found that 94 percent were faculty in academic pediatric departments, and many of those graduates had also obtained federal research grants. Specifically, 42 PSDP graduates who entered the program from 1987 to 1991 had obtained 35 federal grants, including 21 R01 grants, as of 2001 (Hostetter, 2002). Further evidence indicates that PSDP trainees who receive 3 years of fellowship

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Research Training in Psychiatry Residency: Strategies for Reform support may be more likely to receive NIH grants than those trainees who receive 2 years of fellowship funding. Specifically, between 1987 and 2001, 23 of 64 individuals with third-year fellowship funding received federal grant monies, compared with 5 individuals with 2 years of funding. The partial success of this program has encouraged pediatrics to develop the new, accelerated pathways described above. It is hoped that the new programs will attract and retain more researchers by tailoring the training duration to the research and clinical aptitude of the enrollees. TABLE 2-2 Duration in Years of the Two Stages of Pediatric Subspecialty Training Pathways Outlined by the American Board of Pediatrics and the Pediatric Scientist Development Program Activity Standard Pathway (years) Pathways for Those with Significant Prior Research Experience (years) Special Alternative Pathway (years) Pediatric Scientist Development Program (years) Integrated Research Pathwaya Subspecialty Fast Track Pathwayb General Pediatrics Residency 3 3 (1 year for research) 3 2 c 2-3d Subspecialty and Research Training 3 3 2 3 3-4e Total Time 6 6 5 5 5-7f NOTES: a For M.D./Ph.D. graduates or students with significant research experience. b For students with considerable research experience, e.g., Ph.D. or publication record. c Residents must pass an examination at the end of the first year of general pediatric training to permit reduction of general training from 3 to 2 years. d Residents who complete training in 2 years must declare themselves “fast trackers” and are required to pass an examination at the end of the first year of general pediatric training to permit reduction of training to 2 years. e Training includes 1 year of clinical training and 2-3 years of exclusive research training. f Fellows are given assistance in identifying a junior faculty position that will provide 2 years of support with 75 percent time for research. SOURCE: American Board of Pediatrics (2002a); Hostetter (2002)

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Research Training in Psychiatry Residency: Strategies for Reform Both the internal medicine and pediatrics programs described above operate on the principle that general training can be shortened as an incentive to qualified individuals committed to further subspecialty clinical training and extended research training. Shortening of general training is based on two premises. First, superior trainees master clinical skills quickly enough to obviate the need for longer core training. Second, trainees will make up for lost clinical exposure during their subspecialty training (i.e., patient interactions in the context of clinical research and subspecialty clinical service). Additionally, it should be noted that clinical time in fellowship will likely be maximized for patient-oriented researchers, although the programs described are available to those engaged in basic research as well. CONCLUSIONS AND RECOMMENDATION 2.1 Residency is a pivotal interval in psychiatric training. It represents an opportunity to educate all residents for the lifelong practice of evidence-based medicine, to provide some residents with initial research experiences that may launch them on a career of patient-oriented research, and to sustain the research interests of trainees with previous research experience (e.g., M.D./Ph.D.’s). Programs that link residency research training to preceding and subsequent experiences by establishing programmatic and funding pathways will likely ensure the best research training outcomes. Research training programs developed by ABIM and ABP are models for the more direct connection of residency to fellowship research training experiences. To facilitate connectivity between residency and research fellowship in psychiatry, the committee makes the following recommendation: Recommendation 2.1. 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.

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Research Training in Psychiatry Residency: Strategies for Reform This recommendation targets the residency-to-fellowship portion of the training path because fellowship training has the best track record and because post–medical school training experiences are immediately proximal to the point at which a physician matures to vocational independence. At the same time, it should be noted that these fellowships often have not succeeded in attracting the numbers of trainees needed to sustain the physician-researcher workforce. Consequently, early experiences (e.g., medical school–based research exposure) described in this chapter will likely be important in attracting more psychiatrists to patient-oriented research careers. In residency, research tracks (see Chapter 4) are clearly one way to offer special experiences to individuals who commit early to research training paths during residency. In addition, mandatory research didactic learning (e.g., lectures and reading of epidemiology, study design, clinical consent procedures, grant preparation) for all residents may well have the dual benefit of enhancing evidence-based practice and promoting research interest among some residents who might otherwise not consider research careers.

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