3
Regulatory Factors

The previous chapter addressed research training and research exposures that occur before and after residency. This and the next two chapters focus more directly on the residency experience. This chapter details how residency programs, and residents themselves, are regulated by national governing bodies that are designed to ensure that all training programs meet minimal standards, and that all individual trainees attain the necessary skills and knowledge to be certified as psychiatrists. The chapter describes several national professional societies that, in one form or another, have an interest in residency-based training. The impact of these organizations on research training outcomes in residency is addressed. The chapter ends with conclusions and recommendations.

PSYCHIATRY RESIDENCY REVIEW COMMITTEE

Organization and Function

The Psychiatry Residency Review Committee (RRC) is the organization with principal responsibility for setting the minimal standards and content for adult and child and adolescent psychiatry residency training programs. It, along with 24 other medical specialty RRCs, operates under the aegis of the nonprofit and volunteer-driven Accreditation Council for Graduate Medical Education (ACGME, 2002a). As of 2003, the Psychia-



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Research Training in Psychiatry Residency: Strategies for Reform 3 Regulatory Factors The previous chapter addressed research training and research exposures that occur before and after residency. This and the next two chapters focus more directly on the residency experience. This chapter details how residency programs, and residents themselves, are regulated by national governing bodies that are designed to ensure that all training programs meet minimal standards, and that all individual trainees attain the necessary skills and knowledge to be certified as psychiatrists. The chapter describes several national professional societies that, in one form or another, have an interest in residency-based training. The impact of these organizations on research training outcomes in residency is addressed. The chapter ends with conclusions and recommendations. PSYCHIATRY RESIDENCY REVIEW COMMITTEE Organization and Function The Psychiatry Residency Review Committee (RRC) is the organization with principal responsibility for setting the minimal standards and content for adult and child and adolescent psychiatry residency training programs. It, along with 24 other medical specialty RRCs, operates under the aegis of the nonprofit and volunteer-driven Accreditation Council for Graduate Medical Education (ACGME, 2002a). As of 2003, the Psychia-

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Research Training in Psychiatry Residency: Strategies for Reform try RRC had 18 members. The committee’s members are appointed by or sit as ex officio members from one of the following three organizations: the American Board of Psychiatry and Neurology (ABPN), the Council of Medical Education of the American Medical Association (AMA), and the American Psychiatric Association (APA). The ACGME requires that members of an RRC “have demonstrated substantial experience in administrative and/or teaching within the specialty” to qualify for service. Each RRC also includes a single member who is a resident in the appropriate specialty. Appointments are made for 3 years, and members’ terms are limited to 6 years. No provisions exist that specifically require the membership of researchers on the RRC (ACGME, 2002c), and at least two recent Psychiatry RRC chairs have said that researchers do not tend to be members and are not typically involved in the committee’s periodic revision of the written requirements for residency program accreditation (Miller, 2002; Winstead, 2002). The principal responsibility of the psychiatry RRC is to review and accredit individual programs by checking documentation and making site visits to ensure compliance with the requirements set by the committee. Programs found in violation may be cited, and in extreme cases, their accreditation may be suspended or revoked. The accreditation process is designed to safeguard the public by maintaining necessary clinical standards in psychiatric graduate medical education. Additionally, the RRC must evaluate and update the written requirements for residency programs at least every 5 years. The requirements contain a lengthy description of the environment, curriculum, and overall procedures to which departments of psychiatry must conform to be accredited as a residency program in the United States. Accreditation has a direct bearing on two important aspects of graduate medical education. First, one must graduate from an accredited program to qualify for professional board certification as an adult (general) or child and adolescent psychiatrist or in any of the other recognized subspecialties (such as geriatric psychiatry, forensic psychiatry, addiction psychiatry, and pain management). Second, program accreditation is necessary if training institutions are to qualify for federal funding that supports resident stipends, as well as other costs associated with graduate medical education (see the discussion of graduate medical education funding in Chapter 4). In formulating program requirements, the Psychiatry RRC aims to represent the entire field of U.S. psychiatry as broadly and equitably as possible, with regard to both different branches of practice (e.g., geriatrics, addiction, forensics) and different sizes of programs (Miller, 2002). Although this universal approach permits a thorough formulation of

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Research Training in Psychiatry Residency: Strategies for Reform training requirements, it also has a tendency to result in requirements that continually expand, thereby encroaching upon elective time during which a resident might choose to engage in hands-on or more intensive research training. This tendency to add onto existing mandates also appears to have been at least partially responsible for the controversial introduction of a psychodynamic psychotherapy requirement in the recent revision of the RRC requirements that took effect in early 2001. A public exchange between then RRC chair (Daniel Winstead) and then head of the National Institute of Mental Health (NIMH) (Steven Hyman) demonstrates the tension that has arisen because of these requirements, and furthermore highlights the fact that the RRC process is at least in part a political one. The exchange took place during Dr. Winstead’s presentation on training requirements to a small group of experts convened by NIMH and the APA to discuss the general problem of research training in the field of psychiatry (Winstead, 2001). Below is an extract from transcripts of that meeting, which occurred in November 2001. At the time, Dr. Winstead was describing the five psychotherapy requirements mandated by the RRC for all psychiatric training programs as of January 2001. One of the five is psychodynamic psychotherapy. Dr. Hyman: Dan, I’m sorry to interrupt. I just want to highlight this for later discussion. Of course, we support a lot of psychotherapy research, and we would all agree that psychotherapy is absolutely critical. I mean, if you had a heart attack and somebody just wrote you a script [sic] and didn't prescribe psychosocial rehabilitative exercise and interventions, that would be bad medicine. So the problems with psychotherapy are very complicated. It’s interesting that you have psychodynamic therapy up there, and I flag that as a problem. In my five-and-a-half years as NIMH director, we’ve not had a single application come in to study psychodynamic therapy. So in essence, whatever we think historically, you have as a requirement something for which there is no acceptable evidence, and I think we have to, as a field, grapple with what it means that you have succumbed to historical and collegial pressures and have put up as a requirement something that is not evidence-based and for which the practitioners are not even, by NIMH application standards, interested in being in the game. I just want to highlight that because I think it’s a very important point.

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Research Training in Psychiatry Residency: Strategies for Reform Dr. Winstead: It is an important point, and I might tell you that as part of the process, at one point the program requirements went out where we said that the program should pick…[three of]14 these five. I wanted to say that. That’s when we heard in spades from the psychodynamic psychotherapy community about the… Dr. Hyman: Sure. They’re protecting their livelihood…. But the issue is, are we sending a message that…we’re going to require something for which there is no evidence? This exchange clearly demonstrates the reality that preferences rooted in traditional psychiatric practice play a role in both the conception and revision of residency training requirements. The psychiatric research community also must be prepared to engage in the residency training debate, at least to the extent that it is relevant to optimal residency-based research training and the steady evolution of psychiatry as an evidence-based medical discipline. As controversy appears inevitable, the next section detours briefly into a discussion of psychodynamics and considers how it is relevant to residency training and research training. This detour is considered important because the committee is aware of many in the field of psychiatry who are concerned about the inclusion and others about the exclusion of psychodynamic psychotherapy on the competency list for trainees. How this tension is managed has implications for the quantity and quality of research opportunities in psychiatric residency. A Brief Detour into Psychodynamic Psychotherapy Psychodynamic psychotherapy encompasses specific forms of psychotherapy (e.g., talk therapy) involving the application of a variety of theories regarding the psychological adaptive processes that have evolved throughout an individual’s development and that occur at varying levels of conscious awareness. These theories are based largely on conceptions of how early and later adverse life events impact emotions, memories, personality development, and characteristic coping strategies. They often focus on psychological attitudes that conflict with one an- 14   Correction verified per personal communication, D. Winstead, Chair, Department of Psychiatry and Neurology, Tulane University, April 7, 2003.

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Research Training in Psychiatry Residency: Strategies for Reform other. Treatments may be long-term (years), and even shorter-term psychodynamic-based psychotherapies may extend for many months. Although the evidence base for these psychotherapies is weak, new studies and meta-analyses of existing data suggest that some of them may be effective for a variety of psychiatric disorders, including personality disorders (Leichsenring and Leibing, 2003). However, as expressed by Dr. Hyman in the dialogue at the close of the previous section of this report, as well as by other prominent psychiatrists (Eisenberg, 2002; Kandel, 1998), there is concern in the field of psychiatry that the traditional psychotherapies associated with psychodynamics are not sufficiently evidence-based, making their inclusion on the competency list for psychiatry training questionable. Accordingly, some argue that psychodynamic competency training represents a poor use of training resources (especially time), and that it further may drive scientifically oriented trainees away from the practice of psychiatry (see the discussion of intellectual capacity and scientific orientation in Chapter 5). This concern about recruiting scientifically oriented students likely stems from the fact that psychodynamic theory is strongly linked to case studies developed over a century ago (by Sigmund Freud), and based on clinical experience (rather than systematic study) since that time. Conversely, advocates of psychodynamic approaches argue that such methods represent a valuable aspect of psychiatry that not only is part of the field’s uniquely humanistic and patient-centered approach, but also offers a necessary balance to current over-reliance on “quick-fix” remedies (e.g., psychopharmacologic treatment, short-term psychotherapy) for problems that may have complex behavioral and sociologic antecedents (Braslow, 2002). Even well-respected neuroscientists acknowledge that psychodynamics is among “…the most coherent and intellectually satisfying view[s] of the mind” (Kandel, 1999:505), while others, including critics, praise psychodynamics for helping “…psychiatry preserve an abiding interest in the individuality of patients…” (Eisenberg, 2002:32). And most importantly, contemporary research clearly reveals how genetic vulnerabilities interact with life events to yield such devastating mental illnesses as depression (Caspi et al., 2003), suggesting that therapies focused on helping patients understand and better cope with negative experiences are likely to be valuable in treating these disorders. For this report, the committee felt compelled by numerous suggestions from outside its ranks to consider whether the inclusion of psychodynamics as an explicit residency training requirement represents an impediment to psychiatric research training. Despite some concern that the psychodynamic requirement does emphasize a commitment to a method with a limited evidence base, the committee ultimately decided that the

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Research Training in Psychiatry Residency: Strategies for Reform concern about psychodynamics is more a “red herring” with regard to research training in psychiatry than a major issue of concern. The committee is concerned only marginally about the inclusion of a psychodynamic competency requirement for two reasons. First, the committee believes that psychiatrists today are keenly aware of the complexities of treating mental disorders using both psychosocial and psychopharmacologic strategies. Second, the committee is optimistic that impartial research will continue to differentiate therapies according to their effectiveness, but that sound clinical judgment may still be required to provide pragmatic guidance for psychiatric education and practice. The committee’s strong professional impression is that the vast majority of today’s psychiatrists realize that there are both effective biological (e.g., drugs) and psychological therapies for many major mental disorders (see Chapter 1 for a review), and that competent practice requires appropriate selection and use of each or both depending on the clinical situation. It is for this reason that Dr. Hyman noted in the above excerpt that sole reliance on a pharmacologic prescription, even for cardiovascular disease, would be “bad medicine.” Although the committee’s impression is not based on systematic surveys of active psychiatrists, detailed historical review of psychiatric practice demonstrates that psychiatry has emerged as an integrated brain and behavioral discipline since the middle of the twentieth century, when psychodynamics dominated the field (Braslow, 2002). Similarly, and related to the progression of psychiatry, is the evolution of the nature/nurture debate in the behavioral sciences. Regarding that more far-reaching debate, the committee believes that great progress has occurred such that disagreements between those espousing biological determinism and those arguing for the supreme importance of upbringing and social environment have in many ways been transformed into a collaboration—that collaboration being based on a large body of research in recent years that has eloquently demonstrated the influence of both innate genetics and external factors, including psychosocial ones, on behavioral and emotional health (Pinker, 2003). In considering the potential resistance that might ensue from criticism of psychodynamic psychotherapies, one should not confuse psychodynamic psychotherapies with all forms of psychotherapy, and one should also realize that a number of different forms of psychotherapy that deal with conflicts, defense mechanisms, and maladaptive reactions to adverse life events fall under the general rubric of psychodynamic psychotherapy. There are at least seven other schools of psychotherapy that have been codified (Beitman and Yue, 1999). Even if psychodynamics were eliminated altogether from psychiatric training—something the committee considers neither reasonable nor probable—other psycho-

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Research Training in Psychiatry Residency: Strategies for Reform therapeutic approaches would remain important aspects of psychiatric knowledge and practice. This point is made explicitly because the practice of psychiatry in recent years has shifted as a result of the impact of neuropharmacologic advances, as well as cost-saving strategies in mental health that often involve psychotherapy delivery by lower-paid professionals (i.e., psychologists and masters-level therapists rather than psychiatrists) (Olfson et al., 1999). A suggestion that psychodynamic psychotherapies be deemphasized in residency training is not, at least in the committee’s view, linked to shifting psychiatry from a brain and behavioral discipline to one more focused on neuroscience. Instead, such a suggestion is intended to encourage psychiatry as a field to emphasize to residents evidence-based therapeutic strategies that broadly, but objectively, span both the biological and psychosocial interventions that compose psychiatric practice and make it a viable discipline. Finally, with regard to psychodynamic psychotherapies, psychiatric educators should keep in mind that psychiatry is not alone in the broad use of techniques that have not been empirically validated (Eisenberg, 2002). Some estimate that 85 percent of all medical therapies are widely used without having undergone some form of systematic, nonbiased testing (Millenson, 1998). This is likely the case because clinical trials are not easily accomplished, and in some cases may be unnecessary in the face of overwhelming evidence obtained in less systematic ways. This high percentage of unvalidated techniques, however, also points to the need for increasing patient-oriented research and research training toward the ultimate goal of optimizing the practice of evidence-based medicine (Institute of Medicine [IOM], 2001a). Psychiatry, like all branches of medicine, needs to remain vigilant against traditional therapies that not only waste resources, but also can harm rather than heal patients. Such medical fallibility appears to have been exposed recently by a randomized, blind trial of arthroscopic surgery for degenerative arthritis in the knee—a procedure that is performed on 650,000 individuals each year (Moseley et al., 2002). In the absence of complete knowledge, professional disciplines such as psychiatry can decide that certain types of practice are worthy of continued practice and corresponding resident training, and for the moment, psychodynamic psychotherapy may be one of those practices. Alternatively, however, such therapy, along with other theories and practices with a limited evidence base, might be deemphasized to accommodate other educational priorities, including research training. The deemphasis of psychodynamic methods should furthermore be coupled with psychodynamic research and research training by those skilled or interested in such methods. Better evaluation of psycho-

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Research Training in Psychiatry Residency: Strategies for Reform dynamic techniques has been advocated by members of the psychodynamic community (Gabbard et al., 2002). More generally with regard to psychiatric practice, comprehensive increases in evidence-based mental health care have been strongly recommended by a high-profile federal commission (New Freedom Commission on Mental Health, 2003). Clinical Requirements for Psychiatry Training To understand some of the details regarding the Psychiatry RRC and research training, the committee spoke directly with the last two RRC chairs—Sheldon I. Miller, M.D., and Daniel K. Winstead, M.D.—and carefully reviewed and compared the Psychiatry RRC guidelines with those of selected other medical specialties. The committee also spoke with Stephen I. Wasserman, past chair of the American Board of Allergy and Immunology (A&I), to gain insight into the regulatory process that pertains to A&I and internal medicine, as the latter is the foundation of the former. As context for discussion of the Psychiatry RRC requirements, the time and research requirements of clinical training for several specialties and subspecialties are summarized in Table 3-1. Residency training for adult (general) psychiatry is 4 years, 1 year longer than that for general internal medicine and on par with that for several other specialties, including neurology and pathology. Residency training for child and adolescent psychiatry is 5 years (typically composed of 3 years of adult [general] training followed by 2 years of child and adolescent training), placing it on par with A&I training. The committee selected A&I for comparison because a high proportion (9.8 percent) of its subspecialists claim research as a primary activity (Association of American Medical Colleges [AAMC], 2002b). Pulmonology/critical care was selected as an additional field for comparison because it is among the longest residency-plus-fellowship tracks at 7 years, and exemplifies the demands of combined clinical training. Finally, the triple board of pediatrics, adult psychiatry, and child and adolescent psychiatry was chosen as an example of combined training that includes psychiatric training. Table 3-1 lists several medical specialties and the duration of training for each, and notes whether research activity and research literacy are required or encouraged by each specialty’s RRC requirements. The table also lists the proportion of practicing physicians in each subspecialty who claim research as their primary activity, although these data have the obvious limitation of not characterizing those who engage in meaningful patient-oriented research on a more part-time basis. The final two col-

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Research Training in Psychiatry Residency: Strategies for Reform umns of the table were determined by carefully reading the requirements of each specialty, identifying language concerning research education or direct research activity, and characterizing that language as mandatory or suggestive. In many cases, this determination was fairly straightforward, as the ACGME is explicit about the use of the terms “must” and “should.” In other cases, the requirements are vague because, for example, “musts” are nested under “shoulds”; research activity is required for only some residents; or research activity is not differentiated from more generic endeavors such as “academic” activities or “scholarly pursuits.” Despite these limitations, however, the table reflects whether research activity appears to be mandatory (a must) or suggested (a should) for most residents. The committee found no programs in which research is not mentioned, evidence that research content is considered one of the ingredients of medical education. The label of “should/must” is assigned to those descriptions that appear to fall between these designations (i.e., stronger than a “should”, but not definitively a “must”). The triple board program (pediatrics, adult psychiatry, child and adolescent psychiatry) is assumed to conform to the ACGME requirements of its three parent specialties. In addition to interviewing former Psychiatry RRC chairs, the committee carefully read the most recent RRC (2001) requirements for both adult (general) and child and adolescent psychiatry to understand as fully as possible the ACGME-mandated goals of residency training and to focus on the research training didactic learning or practical experiences included in those requirements. The first postgraduate year (PGY1) requires attainment of skills in history taking, diagnosis of mental and other medical disorders, continuous patient care, referrals, and doctor– patient communication. During PGY2 through PGY4, residents are “taught to conceptualize all illnesses in terms of biological, psychological, and sociocultural factors that determine normal and abnormal behavior” (ACGME, 2000b:Section V.A.2). Required clinical training includes “sufficient experiences” in the following: the diagnosis of disorders across a variety of age groups; short- and long-term psychotherapy, including psychodynamic therapy, group therapy, family therapy, and crisis intervention; drug detoxification; continuous care; psychiatric administration; neuropsychological testing; electroconvulsive therapy; and teaching (ACGME, 2000b:Section V.A.2.a). Child and adolescent psychiatrists are expected to master the same clinical concepts as adult trainees, with added emphasis on early brain and behavioral development.

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Research Training in Psychiatry Residency: Strategies for Reform TABLE 3-1 Summary of Duration, Time, and Research Requirements for Accredited Residency Training Programs in Selected Medical Specialties or Subspecialties Specialty/ Subspecialty Research Ratesa (%) Training Duration (months) Time Allocations (monthsb) Effective Datec (mo/yr) Research Requirementsd Activitye Literacyf Internal Medicine (general) 1.5 36   6 – Critical care 3 – Emergency 27 – Other int. med. Subspecialties 7/2001 Must Should Allergy & Immunology 9.4 60   36 – Int. med. or pediatrics 6 – Research and scholarly activities 6 – Other educational activities 12 – Direct patient care 7/2002 Must Must Pulmonology/Critical Care 1.0 72   36 – Int. med. 12 – Critical care (CC) 6 – Pulmonary disease (PD) 18 – CC/PD and other 7/1999 Must Must Pathology, Anatomic & Clinical 4.6 48   18 – Anatomic path (AP) 18 – Clinical path (CP) 12 – AP/CP or specialized training 7/2002 Should Should

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Research Training in Psychiatry Residency: Strategies for Reform Neurology 6.3 48   8 – Int. med./pediatrics 18 – Adult neurology 3 – Child neurology 2 – Core sciences 17 – Other 4/2002 Should/must Must Adult (General) Psychiatry 2.1 48   4 – Int. med./ pediatrics/family med. 2 – Neurology 42 – Psychiatry 1/2001 Should/must Should Child & Adolescent Psychiatry 1.9 60   36 – Adult psychiatry 24 – Child & adolescent psychiatry 1/2001 Should/must Should/must Triple Boardg N/Ah 60   24 – Pediatrics 36 – Adult and child & adolescent psychiatry 12/2001 N/Ah N/Ah aProportion of physicians in specialty who claim research as their primary activity (same as used in Table 1-1). bVacation time not considered. cDate when requirements were put into effect by the respective RRC, or the American Board of Psychiatry and Neurology for the triple board. dIndicates whether written RRC requirements state that research activity by residents “must” or “should” be done, the former being a necessary component of training, the latter being an encouraged option of training. eRefers to hands-on involvement in activities aimed at generating new medical knowledge. f Refers to classroom teaching designed to give residents book knowledge about research concepts and methods. g Assumed to conform to requirements of the 3 individual specialties: pediatrics, adult [general] psychiatry, child and adolescent psychiatry. h N/A = not available. SOURCE: Data obtained from AAMC (2002b), ABPN (2003a), ACGME (2002a), Pasko and Seidman (2002).

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Research Training in Psychiatry Residency: Strategies for Reform CERTIFICATION BOARD, AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY As noted earlier, the ABPN is one of three groups that appoint members to the Psychiatry RRC. The ABPN is responsible for five appointments (three ABPN directors and two child and adolescent psychiatrists) to the Psychiatry RRC and has input into the process for formulating program requirements. In contrast with the Psychiatry RRC, which accredits residency training programs, the ABPN certifies individual psychiatrists by means of written and oral examinations and an audit of specific training experiences leading up to those examinations (ABPN, 2003b). The ABPN examination focuses primarily on direct patient care issues in which certified clinicians should be proficient (see Box 3-3). There are virtually no questions devoted to research methodology and data analysis, with the possible exception of a few questions on statistics in the epidemiology section and on experimental psychology approaches in the behavioral and social sciences section. As of April 2003, the ABPN had no official policies regarding research training during residency and had not implemented or suggested training pathways that would support research in residency (personal communication, S. Scheiber, ABPN, April 3, 2003). Although most other specialty boards also lack research tracks, the dermatology, anesthesiology, pediatrics, and internal medicine boards, at least, have developed such pathways (Hostetter, 2002; IOM, 1994). The pediatrics and internal medicine pathways are described in Chapter 2. The dermatology training track is similar to the regular track that includes basic or clinical research training for all residents, but the research track allows the explicit integration (in lieu of other training activities) of investigative or didactic experience after PGY2 has been completed (American Board of Dermatology, 2003). The anesthesiology pathway has two options: option A involves 6 months of clinical or basic research in the context of a 48-month residency; option B involves 18 months of research in the context of a 60-month residency (The American Board of Anesthesiology, 2002). The ABPN has considerable influence on residency-based research training in at least three ways. First, as noted above, the ABPN appoints one-third of the membership to the Psychiatry RRC. Second, it must approve all applicants for the certification examination, and this approval process involves retrospective determination of whether a given applicant completed all the prescribed RRC requirements (e.g., months of clinical service). Third, the ABPN is responsible for the content of the certification examination, thereby encouraging residents to learn certain

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Research Training in Psychiatry Residency: Strategies for Reform facts and concepts in lieu of others (ABPN, 2002). Thus it is arguably the principal national organizing body that can impact residency training, and residency-based research training efforts that are not in some fashion sanctioned or promoted by the ABPN are likely to have more limited success than those that are. BOX 3-3 Summary of Topics Included on Written Portion of Psychiatry Board Examination Topic Number of Questions Psychiatry Content (total 260 questions) Psychiatric disorders 78 Treatments 78 Neuroscienes 26 Diagnostic procedures 23 Brain and psychosocial development through the life cycle 16 Behavioral and social sciences 13 Epidemiology and public policy 13 Special topics (e.g., suicide, emergency psychiatry) 13 Neurology Content (total 160 questions) Clinical evaluation 56 Basic science of neurologic disorders 32 Diagnostic procedures 32 Management and treatment 32 Incidence risk 8 Total number of questions on Part I examination 420 NOTE: The approximate number of questions devoted to each topic area was calculated from content percentages specified in outline form at the ABPN website. SOURCE: ABPN (2002).

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Research Training in Psychiatry Residency: Strategies for Reform AMERICAN MEDICAL ASSOCIATION The AMA Council on Medical Education (CME) nominates six (five voting, one ex officio) members to the Psychiatry RRC. Although experience in graduate medical education is a very important selection factor, research experience is not necessarily considered relevant (personal communication, B. Barzansky, AMA, October 22, 2002). In its 2002 annual report to the AMA membership, the CME commented about a great variety of issues affecting graduate medical education, including resident work hours, Medicare funding for graduate medical education, and medical school debt. Research training was not explicitly mentioned in this report, although the importance of continuous evaluation of best practices in medical education was a clearly stated goal (CME, 2003). Given the importance of training clinical scientists to develop and validate contemporary best practices, one can only assume that the AMA would support efforts to enhance research training in the psychiatric residency. OTHER NATIONAL ORGANIZATIONS INVOLVED IN PSYCHIATRIC RESEARCH TRAINING American Psychiatric Association In addition to the ABPN and the AMA, professional societies for psychiatrists have addressed and fostered research training. The APA is the largest, with nearly 40,000 members (APA, 2002b). Its Division of Education, Minority, and National Programs nominates directors to the ABPN, and also appoints six members (five full, one liaison) to the Psychiatry RRC. The APA also operates the American Psychiatric Institute for Research and Education (APIRE) and the Council on Research (COR), which administer educational, lobbying, and research training activities that promote and develop mental health research and awareness at the national level. As described in Chapter 2, APIRE and the COR manage several research fellowships. The COR has created an annual Research Colloquium for Junior Investigators, which is timed to coincide with the annual APA meeting. Started in 1996, the program provides 45 awards (of $1000 each) annually to senior residents, fellows, and junior faculty to attend a 1-day meeting. At that meeting, they discuss their research goals with peers and senior psychiatric researchers, who offer ad-

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Research Training in Psychiatry Residency: Strategies for Reform vice and guidance regarding a research career (APA, 2003). A retrospective study of participants in the colloquia from 1996 to 1999 found that 114 of the 118 respondents reported some continued degree of research involvement since participating (APA 2002c). Of that group, 67 had received local department research funding, and 80 had received external funding, including 35 federal grants, as principal investigators (APA 2002c). Although these data cannot be used to assess the impact of the colloquia, they do suggest that the program is succeeding in bringing together a good number of newly developing psychiatrist-researchers. American Academy of Child and Adolescent Psychiatry The American Academy of Child and Adolescent Psychiatry (AACAP) is a professional society of child and adolescent psychiatrists with more than 6,000 members. Unlike the APA, the AACAP does not have the authority to appoint members to the Psychiatry RRC. However, it does have several small-scale research training initiatives. These initiatives, funded by the federal government and pharmaceutical companies, provide fellowship (see Chapter 2 for more detail) or seminar experiences (AACAP, 2002a; 2002c; 2002d). Somewhat analogous to the APA colloquia, the Early Investigators Group (EIG) was initiated by the AACAP in 2000 to facilitate the development of new researchers by providing a venue for professional networking and informal peer review (AACAP, 2003a). The AACAP has also convened a task force to develop a residency-based curriculum aimed at training child psychiatrist-researchers and one that that also integrates research content throughout the residency (i.e., beginning in PGY1 and continuing through the final year) (see the description in Chapter 4) (personal communication, J. Leckman, Yale University, April 4, 200318). Key features of this curriculum are an emphasis on core competencies that include “research skills,” and opportunities for outstanding students to accelerate their training to permit increased time for hands-on research over the course of a 5- or 6-year residency training period. 18   Communication via the following document: Version 5.0 (February 2003) of Integrated Residency Training in Child and Adolescent and Adult Psychiatry, a product of a task force assembled by the AACAP.

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Research Training in Psychiatry Residency: Strategies for Reform Other National Organizations Other national organizations relevant to psychiatric practice and research training include, but are not limited to, the American Association of Directors of Psychiatry Residency Training (AADPRT), the American Association of Chairs of Departments of Psychiatry (AACDP), the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), and the American College of Neuropsychopharmacology (ACNP). These organizations represent the perspectives of residency training directors, department chairs, student clerkship directors, and psychopharmacologists, respectively. None of them has a direct impact (i.e., nominating or voting rights) on the Psychiatry RRC or the ABPN. Nevertheless, some organizations, such as the AADPRT, may have an impact on RRC requirements, as AADPRT members are asked to comment on new RRC requirements before these requirements are finalized.19 Moreover, these organizations interact regularly with RRC representatives at meetings and in the context of ongoing program accreditation and review processes. Over the course of this report, it became clear to the committee that all of these organizations have at least some appreciation for the importance of research and research training opportunities in the context of psychiatric residency, although many tend to be focused on more immediate, day-to-day clinical training and practice issues. CONCLUSIONS AND RECOMMENDATIONS The two regulatory bodies with the greatest influence over residency training are the Psychiatry RRC and the ABPN. The committee understands and respects the fact that these two bodies aim to safeguard consumer health by ensuring that residency graduates are trained to deliver quality psychiatric care. We also understand that a national regulatory effort is complex and that defined requirements (both timed and untimed) are useful in the documentation of residency training. At the same time, the committee believes the requirements are so expansive and prescriptive that they impair the development of timely research training experiences for residents; and requirements currently exist that are redundant or do not represent the best available evidence-based practices in psychiatry. Given the apparent excessive nature of the requirements and the universal belief that protected time for research activity is critical for re- 19   A public comment period is part of the formal approval process used by all ACGME committees.

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Research Training in Psychiatry Residency: Strategies for Reform search 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: 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. This recommendation is aimed at optimizing core training by minimizing redundant and non–evidence-based aspects of that training, and by giving programs and individuals the opportunity to tailor larger portions of their training to incorporate 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 clear guidelines from both the RRC and the ABPN. This guidance might be delivered most efficiently if the RRC and the ABPN jointly published a clearly defined checklist for use by training directors and residents in determining what requirements and electives must be fulfilled for accreditation and certification. Implementation of this recommendation will also depend upon the development of criteria for determining when and whether a resident has developed a level of competency that warrants special advancement into an accelerate research track. Although the development of such criteria poses logistic challenges for training programs, existing instruments, such as the Psychiatry Resident In-Training Examination (PRITE), could be used along with supervisor evaluations to certify accelerated resident competency (American College of Psychiatrists, 2002). At the same time that the committee advocates increased flexibility in clinical requirements, we also believe that the research requirements

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Research Training in Psychiatry Residency: Strategies for Reform of residency training must be strengthened if the field of psychiatry is to keep pace in the age of evidence-based medical practice. Although the RRC requirements do offer research experiences and didactic learning as clear “shoulds,” most programs appear to offer very limited research training to their residents (Balon and Singh, 2001), and even the strongest programs delay research experiences until late in the residency (see Chapter 4). 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 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. Both the ABPN and the Psychiatry RRC must recognize that patient-oriented research and patient care are inextricably linked. This should include accreditation and credentialing requirements that make research literacy essential and research experiences desirable goals of all residency programs toward the aim of training clinicians who will be capable of incorporating the latest knowledge into their practice. Gaining research experience in addition to literacy is important for two reasons: first, research experiences contribute to literacy by allowing residents to understand the challenges and details of research activity; second, the opportunity to engage in research work may convince some residents of their unique talent for or interest in such activity. Recommendation 3.2 should be implemented by strengthening the language in the Psychiatry RRC requirements to indicate that all residents should be familiar with research design and methods such that they are prepared for the lifelong practice of evidence-based medicine. As currently written, the requirements for research training are ambiguous: on the one hand, they say “a program must promote an atmosphere of scholarly inquiry including the provision of ongoing research activity in psychiatry [emphasis added],” but on the other hand, they say that the “didactic curriculum should include…research methods in the clinical and behavioral sciences related to psychiatry [emphasis added].”

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Research Training in Psychiatry Residency: Strategies for Reform The ABPN could further enforce the literacy requirement by adding more questions on the certification examination designed to explicitly test research literacy. Content for the examination and for program didactics in the context of residency training could come from any number of works on clinical research in psychiatry or other branches of medicine, works that could also be used to design research literacy curricula. Blazer and Hays (1998), for example, crafted a text that uses real-world, peer-reviewed examples to teach readers the concepts and shortcomings of scientific inference, study design, and analysis and interpretation as these concepts pertain to clinical research in psychiatry. The next chapter describes several other curricula in clinical research. To best develop these competencies and also optimally integrate research training into residency training, the involvement of researchers in the full educational development process will be important. Thus, the following recommendation is made: 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. As discussed above, research experience is not currently an explicit requirement for nomination to the Psychiatry RRC or to the ABPN, yet there is concern among both regulatory bodies and among researchers themselves that experienced researchers are not sufficiently involved in the formal expectation-setting process for residents. It is the committee’s view that at least some of the slots on those regulatory bodies should be filled with individuals who are skilled as patient-oriented researchers. Their involvement would greatly increase the probability that accreditation and certification policies will be influenced by those with first-hand knowledge of what a career in patient-oriented research requires. Implementation of recommendation 3.3 could be undertaken by one of the nominating bodies (e.g., APA, AMA) or through a change in the written nomination policies of the ACGME and the ABPN to mandate the inclusion of a certain number of patient-oriented researchers. Implementation of this recommendation will obviously be limited by the relatively small number of researchers in the field. Therefore, re-

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Research Training in Psychiatry Residency: Strategies for Reform searchers themselves should be prepared to sacrifice some time to contibute to the educational mission, while others in psychiatry should consider how to make these service responsibilities tenable to those who might prefer to be otherwise engaged. For example, service on the ABPN executive board requires a commitment of 45 days per year (personal communication, S. Scheiber, ABPN, April 3, 2003). For those with a sizable research program, a 45-day (or even a much shorter) commitment may be impossible unless their department chair or extramural funding agency offers them some reprieve or extension on existing obligations (e.g., a no-cost extension, supplemental support). As an alternative to full committee service, such researchers could be called upon to serve on subcommittees or in other more limited capacities. Regardless of the form it takes, the goal of such researcher involvement in ABPN and RRC affairs should be for experienced patient-oriented researchers to have a genuine and measurable impact on the requirements and priorities established each year by these regulatory bodies. Compromise on the part of those who have traditionally served on these bodies and a sacrifice of time by researchers who have sometimes avoided such service will both be necessary if this recommendation is to be implemented. Although this chapter focuses on regulatory issues, which in this case involve the oversight of the Psychiatry RRC and the ABPN, these bodies do not act in a vacuum. A number of other national stakeholders (e.g., the AADPRT, APA, and AACAP) have an interest in residency training, although their approach appears typically to consist of offering small initiatives, such as 1-day seminars, or targeting postresidency trainees for research support in the context of fellowships (see above and Chapter 2). Nevertheless, these efforts appear to be focused sincerely on increasing research training in psychiatry, including the residency context. A notable example is the AACAP’s recent initiative to develop and broadly disseminate a model curriculum for child and adolescent psychiatry residency programs interested in infusing more research into their training curriculum. This initiative, though spearheaded by the AACAP, was undertaken with the cooperation of both the RRC and the ABPN (personal communication, J. Leckman, Yale University, April 4, 2003; personal communication, S. Scheiber, ABPN, April 3, 2003). These efforts indicate that a national consensus is emerging with regard to the importance of residency-based research training; Chapter 6 addresses the importance of harnessing that emerging consensus to further the cause. Finally, it should be noted that regulatory guidance and constraints on programs do not act in isolation. The policies of the Psychiatry RRC and the ABPN clearly set values for the entire field, but these organizations do not directly train residents to be researchers. Local institutions

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Research Training in Psychiatry Residency: Strategies for Reform need to provide resources and opportunities, including research time, mentors, and a culture that genuinely values the importance of generating new clinical knowledge. The next chapter details the state of research training at the institutional level.

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