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Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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4
Institutional Factors

The last chapter focused on regulatory issues that influence psychiatric research training during residency, noting that national oversight of the residency accreditation and board certification processes has considerable influence on the goals of residency training, research literacy, and research training. This chapter looks more directly at the programs themselves, considering the obstacles and strategies of institutions and departments regarding research training during residency. As financial constraints are central to this subject, the chapter begins with a brief discussion of how residency education is typically funded in the United States. It then addresses two key institutional factors that influence research training during residency: leadership and mentoring, and program and curriculum structure. The chapter ends with conclusions and recommendations that include a theoretical framework for evaluating institutions that aim to offer research education to psychiatry trainees.

FUNDING ISSUES IN GRADUATE MEDICAL EDUCATION

The General Funding Stream

Graduate medical education (GME) funding for all residents comes primarily from the following sources: Medicare, Medicaid, the Veterans Administration, the Department of Defense, the National Institutes of Health (NIH), and the private sector (see Table 4-1) (Anderson et al.,

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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2001). As the numbers in Table 4-1 indicate, Medicare is the largest single source of GME funding. Medicare is also currently the most reliable source of GME funding because federal law requires annual entitlement payments to institutions that serve Medicare patients to subsidize both “direct” and “indirect” costs associated with training new physicians. Direct medical education (DME) payments subsidize resident stipends and benefits, faculty teaching time, and educational infrastructure. Indirect medical education (IME) payments, which are nearly twice as large as DME, are designed to subsidize the less visible costs associated with GME, including the fact that trainees tend to deliver less efficient care than do more experienced physicians (e.g., overprescribing tests), and that teaching hospitals typically treat the most severely ill patients. In an effort to minimize short-term operating costs, nongovernmental third-party payers are inclined to avoid GME costs that do not relate directly to patient care (e.g., certain IME costs or stipends for residents doing research training) (Knapp, 2002). This inclination has placed general financial pressure on the educational mission of institutions that train residents. It has also led to the introduction of proposed federal legislation aimed at ensuring that all users of medical care contribute equally to GME funding—legislation that was originally introduced by the late Senator Moynihan (D-NY) in 1999 and that has the strong support of the Association of American Medical Colleges (AAMC, 2001).

TABLE 4-1 Sources of Graduate Medical Education Funding

Source

Amount (billions of dollars)

Medicare

7.8a

(2.7 direct, 5.1 indirect)

Medicaid

2.3b

VA/DOD/NIHc

2.0d

Private-Sector Payers

6.0

NOTES:

aYear: 2000.

bYear: 1998.

cVeterans Administration/Department of Defense/National Institutes of Health.

dIn 2001, NIH training grants and fellowships accounted for $300 million of this amount. As these training and fellowship grants include Ph.D.’s and medical residents, the NIH contribution to GME is well below that $300 million dollar amount.

SOURCE: Anderson et al. (2001).

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

Funding Issues in Pediatric Graduate Medical Education

Institutions that treat predominantly pediatric populations may receive lower amounts of GME funding than other institutions because they are less likely to treat Medicare’s primary beneficiary—the elderly. As a result, they are dependent upon non-Medicare sources, which are not entitlements and are subject to annual local or federal appropriations processes (Henderson, 2000).20 Although child and adolescent psychiatry residents at Medicare-funded institutions are considered 100 percent full-time equivalents (FTEs) for reimbursement calculation purposes, the reimbursement is based on an institution’s Medicare utilization, an index that reduces the reimbursement rate for institutions with a high pediatric caseload. Additionally, in child and adolescent psychiatry, as with all Accreditation Council for Graduate Medical Education (ACGME)-designated subspecialties, GME coverage drops to 50 percent for each FTE in postgraduate year 5 (PGY5) (ACGME, 2000a) because the Medicare law offers full reimbursement only for what the ACGME defines as “general” training (American Academy of Child and Adolescent Psychiatry [AACAP], 2002b).21 It is notable that child and adolescent psychiatry is considered a subspecialty of adult (general) psychiatry, even though pediatrics is not considered a subspecialty of internal medicine.

Supporting Research Activity Through Graduate Medical Education Funds

Research training is peripheral to immediate clinical care. Consequently, there are some limits on the use of Medicare GME funding to cover residents engaged in research training activities. A review of federal regulations pertaining to GME reimbursement from Medicare indicates that neither DME nor IME reimbursements are intended to cover activities outside of patient care.21,22,23 One regulation explicitly states: “The time spent by a resident in research that is not associated with the treatment or diagnosis of a particular patient is not countable.”22 This regulation clearly excludes “basic research” on nonhumans, although it

20  

Healthcare Research and Quality Act of 1999. Pub. L. No. 106-129 (1999); Children’s Health Act of 2000. Pub. L. No. 106-310 (2000).

21  

Direct Graduate Medical Education Payments. 42 C.F.R §413.86 (2001).

22  

Special treatment: Hospitals that incur indirect costs for graduate medical education programs. 42 C.F.R. §412.105 (1999).

23  

HHS (Health and Human Services). Counting Research Time as Direct and Indirect GME Costs. F.R.66(148): 39896. 2001.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

does not necessarily limit patient-oriented research, especially if such activity involves regular patient contact.

Since the federal regulations additionally defer to the ACGME for determining the legitimacy of reimbursable resident activities, there is room for educational activities not exclusively linked to billable clinical productivity. Nevertheless, the concern that funding may be reduced if residents engage in research training adds uncertainty to an already tenuous stream of federal support for residency training in general. This concern prompted officials at the University of Michigan to obtain a grant from the National Institute of Mental Health (NIMH) to cover their psychiatry residency-based research training program (McCullum-Smith, 2002). Concern has also been heightened in the New England area as that region’s Medicare intermediary has asked institutions to refund GME money that supported residents engaged in “bench” research. Although the action targeted surgery residency programs that permitted a full “year-out” for residents to conduct basic laboratory work, it has had a discouraging effect on residency-based research training initiatives more broadly, especially those that involve basic research training components (personal communication, S. Benjamin, University of Massachusetts Medical School, July 22, 2002).

The committee validated the above described Medicare restrictions on research activity by interviewing GME directors at institutions in Arizona, Arkansas, Georgia, and Washington State. These GME directors verified that research, and especially basic research activity by residents, typically is not reimbursable by Medicare. They also indicated that increased scrutiny by Medicare intermediaries is part of a more general effort among third-party payers to control their costs. At the same time, these GME directors were all aware that clinical research activities that encompass the diagnosis and treatment of patients are reimbursable under Medicare, although they acknowledged that the regulations are sometimes confusing to those engaged in the accounting process.

A further and important consideration is the institutional flow of GME dollars. These funds usually are directed to hospitals rather than to departmental residency programs, and federal legislation dating back to 1986 prevents expanding the numbers of medical residents funded by Medicare (Knapp, 2002).24 Given the variability in institutional and departmental needs, GME funding for psychiatry training programs may or may not be proportional to the size of those programs. Training slots may be reallocated to other departments, or IME dollars, which are tendered by an institution to support the general training environment, may not

24  

Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L. No. 97-272 (1986).

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

proportionally finance all departments responsible for training residents. Thus, the flow of funds to support residency and fellowship training may be more generous for one program than another, adding to the uncertainty faced by individual training programs regarding their operating budgets.

It is unclear whether GME funding adequately covers the true cost of training the next generation of medical doctors. What is known, however, is that resident compensation is far below what entry-level physicians earn after graduating from residency—a reality that has prompted some analysts to argue that residents themselves bear considerable cost in the training endeavor (Newhouse and Wilensky, 2001), and that furthermore is tied to a recent lawsuit by 200,000 medical residents claiming that the GME matching system supports the economic exploitation of physician trainees (AAMC, 2003; Miller and Greaney, 2003).

Additionally, cost-saving measures in recent years have eroded general GME funding streams to teaching hospitals, as well as direct and indirect streams of capital to research training. Moreover, residency funding for pediatric programs, including child and adolescent psychiatry programs, is currently even less secure than funding for programs involving a substantial Medicare patient load.

The above are key financial realities faced by all U.S. residency training programs, including those that train psychiatrists.

General Research Funding

Layered over the GME funding constraints described above are the general financial challenges imposed by the emergence of managed care. Across all of medicine, clinical reimbursement rates have decreased, yielding lower per-hour incomes for individual physicians and for the departments in which they serve. As a result of lower clinical incomes, residents and faculty have less discretionary time for research and research mentoring because they need to increase clinical volume to compensate for the lower reimbursement rates (AAMC, 2002b; Beresin, 1997; Ludmerer, 1999; Mirin, 2002; Pardes, 2002). Additionally, lower clinical income reduces the surplus revenues traditionally used by institutions to cross-subsidize research and other activities not encompassed by the clinical mission (AAMC, 1999; Jones and Sanderson, 1996). A recent study by the Commonwealth Fund Taskforce on Academic Health Centers (1999) found that nearly 10 percent of research at academic health centers is supported by surplus from faculty practice plans. Perhaps even more important, Moy et al. (1997) found that managed care

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

penetration not only decreases surpluses from clinical work, but also appears to discourage institutions from seeking federal research dollars. This finding is particularly important as federal grants account for nearly 70 percent of the research funding for academic health centers (Commonwealth Fund Taskforce on Academic Health Centers, 1999).

For departments of psychiatry, shortages in clinical income may be even more acute. Despite the recent introduction of mental health parity laws that have required some insurers to cover mental disorders at levels similar to those for other diseases, full mental health care coverage remains patchy both geographically (i.e., state by state) and with regard to the extent of coverage (e.g., small employers have been exempt from federal provisions, and parity for addiction is often excluded) (Frank et al., 2001b). Recent estimates cited in the Surgeon General’s Report on Mental Health indicate that as of 1997, medium to large corporations were offering mental health benefits to their employees valued at 3 percent of the total medical benefits, down from 6 percent just 10 years earlier (DHHS, 1999; HayGroup, 1999). Given the increased awareness of mental disorders and treatment that occurred during this decade (see Chapter 1) and the Surgeon General’s estimate that mental disorders account for more than 15 percent of the disease burden in industrialized countries, a 3 percent insurance benefit appears disproportionately low. Another analysis reported by the Surgeon General determined that if a family experienced $35,000 in mental health expenses during a given year, that family would be responsible for $12,000 out of pocket, compared with only $1,500 in out-of-pocket expenses for equally costly medical/surgical care in the same year (Zuvekas et al., 1998). This lack of insurance/reimbursement equity adds to the financial pressure faced by psychiatrists and other mental health practitioners with regard to declining clinical revenues secondary to managed care, and diminishes the opportunity to partially fund clinical research from patient care revenues.

These financial realities exist in an age when patient-oriented research costs are increasing as a result of the growing complexity of such investigative endeavors (AAMC, 1999). Psychiatric research, like other biomedical research, relies on a multidisciplinary team approach (Beresin, 1997; Institute of Medicine [IOM], 2000; Meador-Woodruff, 2002; Meyer and McLaughlin, 1998; Roberts and Bogenschutz, 2001). For example, a brain imaging study of psychiatric patients requires not only considerable material investment in scanning equipment and facilities, but also ongoing technical support from various experts, including psychiatrists, physicists, neuroscientists, computer programmers, psychologists, and biostatisticians. The administrative costs of research have also risen in recent years because of increasing institutional and govern-

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

mental oversight aimed at protecting the rights and safety of research participants and at ensuring that research dollars are well utilized (Holmes et al., 2000; Miller, 2001; Shalala, 2000).

The above discussion characterizes the challenges of obtaining funding for GME and research activity more generally. Most of these constraints are not unique to psychiatry, but affect other branches of medical practice and research as well. Constraints on these resource streams logically translate into a short supply of money to finance the research training activities of residents and the underlying infrastructure needed to support that training.

A Business Case for Research

Despite the above financial limitations, many programs incorporate research and research training into their broad departmental activities. They do so largely because new knowledge, especially as it relates to enhancing patient care, fits naturally into the philosophy of most clinical departments and institutions. Nevertheless, the ideal of research and research training can be at odds with the immediate needs of patients and the financial bottom line of departments. Accordingly, the committee believes a specific business case for research and research training should be aggressively pursued by psychiatry departments and should be formalized as part of a department’s financial plan. This business case should include metrics to measure both the direct and indirect benefits of research activity and research training within a department.

Regarding the direct financial benefits of research, the committee was able to identify only one study, by Chin et al. (1985), that compares research-generated departmental income with income from clinical activity. This study found that research activities yielded far more departmental revenue per faculty FTE than the faculty clinical practice plan ($944,000/year versus $250,000/year).25 Chin et al’s. work is based on 1981 data from a large and relatively wealthy department (Stanford University’s Department of Internal Medicine), so it has limited contemporary applicability and does not necessarily support a business case for research in less resource-intensive settings. Furthermore, Chin et al. do not factor in the resources necessary to support faculty during periods when grants are not funded or clinical volumes are not achieved. Never-

25  

Based on a sample of 52 FTEs who, on average, spent 27 percent of their time on federal or other extramurally funded research.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

theless, the study does indicate that departments can develop measures of the financial return related to research activity.

Metrics or accounting systems have been developed to quantify the departmental income and relative value of research compared with other activities, including clinical and teaching responsibilities (Kastor et al., 1997; Scheid et al., 2002). Although the committee is not aware of any studies that have used metrics to demonstrate the financial benefits of a sustained research effort by medical departments, it is reasonable to hypothesize that such metrics could help individual departments determine the feasibility of using intramural resources to pursue the goal of building an extramurally funded research portfolio. Finally, analogous metrics could be used to assess less direct benefits of department-supported research, such as the prestige or faculty or patron satisfaction associated with research activity. Specifically, successful research programs are likely to attract the most ambitious faculty and trainees, as well as patients, third-party payers, and benefactors who are interested in having access to and supporting cutting-edge technologies (Pardes, 2002).

Strategies for Funding Smaller Programs

Building a research program or research training effort in less resource-intensive settings is more challenging than sustaining a large, existing program. The current reality is that some institutions receive considerable federal funding, whereas the rest receive little or none (Brainard, 2002). Psychiatry is no exception in this regard, as most psychiatric research funding is concentrated in the top 10 to 15 percent of psychiatry departments nationwide (Pincus, 2002). Specifically, in 2002 the top 10 NIH-funded departments obtained a combined total of nearly $365 million, while the next 75 departments received a total of $386 million (NIH, 2003b). For child and adolescent psychiatry, the concentration of research wealth is even greater, with fewer than 10 child and adolescent divisions having a substantial research effort (Beresin, 1997). In internal medicine departments, by comparison, the concentration of research resources is less severe, with the top 10 departments obtaining a total of $893 million, compared with $1.615 billion for the next 75 departments (NIH, 2003b). Thus the top 10 departments in psychiatry obtained nearly 49 percent of NIH funding for that discipline, whereas the top 10 in internal medicine received only 36 percent of the corresponding aggregate funding. Consequently, it may well be that many or most psychiatry departments lack the technological infrastructure and critical

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

mass of researchers necessary to effectively support comprehensive research activity and training.

The obvious way for these smaller departments to build a research and research training effort is to seek extramural support. However, the disparity between resource-rich and resource-poor programs makes it difficult for the latter to compete for extramural support because funding agencies, especially those that fund training or early career award grants, are interested in the resources and environment of the applicants’ institution, including the qualifications of mentors or senior investigators. The general challenge of obtaining extramural funding has become even greater because the NIH budget-doubling initiative is complete as of 2003, and because significant declines have occurred in the U.S. economy since early 2001.

Nevertheless, numerous private and public extramural funding options exist for biomedical researchers. Appendix B lists several government, foundation, and industry grants that support research training or research infrastructure during or in close temporal proximity to residency. Some of the sources of extramural research support are also summarized below.

Large grants from NIH. Building infrastructure is important to small programs that wish to compete with larger institutions, attract quality researchers, and sustain research efforts. Two infrastructure grants—the Centers of Biomedical Research Excellence (COBRE) and the Biomedical Research Infrastructure Network (BRIN)—target 23 states and Puerto Rico, as these localities have historically been low utilizers of NIH funding mechanisms. Accordingly, these mechanisms may be models for the establishment of research infrastructure at institutions with less resource-intensive departments of psychiatry.

The BRIN and COBRE grants are designed to build local biomedical research infrastructure, including personnel recruitment and training efforts, in regions having the greatest need for resource expansion. Considering that more than 50 percent of all NIMH funding goes to four states (New York, California, Pennsylvania, and Massachusetts)26 (NIMH, 2001a), it appears reasonable for departments of psychiatry in other states to consider these infrastructure-building grant mechanisms or other funding opportunities that target underrepresented regions or small departments. NIMH might encourage applications for these or similar funding mechanisms by marketing them more aggressively to small or emerg-

26  

Census data for 2000 indicate that the population in these four states is 27 percent of the entire U.S. population.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

ing programs, and by encouraging resource-rich programs to partner with smaller programs such that the latter can enhance their research efforts while the former work to expand their geographic perspective and access to patient populations.

The first BRIN (3 years in duration) and COBRE (5 years in duration) grants were awarded in 2000 and 2001, respectively. The BRIN grant is aimed at fostering collaboration among different institutions within one state, whereas the COBRE grant is awarded to one institution that may or may not collaborate with others. The BRIN grant encourages the creation of a research infrastructure that will attract research scientists. The COBRE grant operates with one senior scientist who fosters the development of junior investigators; to receive a COBRE grant, an institution must establish three to five multidisciplinary research projects. The maximum amount given to a state for a BRIN grant is $2 million/year (each state may submit no more than two applications for potential funding) (NIH, 2000b). The maximum amount given to an institution for a COBRE grant is $1.5 million/year, with a limit of three simultaneous submissions (NIH, 2001b; 2002c).

As of spring 2003, most research projects funded under these infrastructure mechanisms support basic research, although clinical research is permitted. None of the funded grants focus on training psychiatry residents, although approximately 40 percent have a neuroscience component. The projects funded thus far are reviewed individually on an annual basis. A systematic and broad review of their overall success in terms of research productivity is not anticipated until 2004 (personal communication, F. Taylor, National Center for Research Resources, April 10, 2003).

The NIH General Clinical Research Center (GCRC) grant is another model that can be used by NIH and other institutions to build research programs at less research-intensive institutions. Departments should consider these centers for the development of fledging research projects and training opportunities. Approximately 80 GCRCs currently support inpatient and outpatient facilities, core laboratories, bioinformatics programs, biostatisticians, and administrative technical personnel, all of which can be utilized by subscribing investigators at relatively modest cost (AAMC, 1999). Several GCRCs across the country have behavioral assessment cores that can assist with psychiatric research efforts (NIH, 2003a). Although these centers are at large, well-established institutions and are intended to support established investigators with peer-reviewed research funding, NIH encourages GCRCs to expand their efforts by supporting new training and research grants. Specifically, this means GCRCs are encouraged to support fledgling investigators conducting pilot studies and ultimately aiming to submit training or other grant ap-

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

plications themselves. GCRCs can support these new investigators or trainees by offering logistic (e.g., human subject informed consent), scientific (e.g., statistical), and infrastructure (e.g., inpatient and outpatient facilities) resources.

Industry or philanthropic support. There are numerous other sources of research and research training funds in addition to the federal funding mechanisms described above and in Appendix B. In a presentation to the committee in June 2002, Herbert Pardes, chief executive officer (CEO), New York Presbyterian Hospital (former director of NIMH), suggested that surplus income from industry-sponsored trials could be earmarked for departmental research. Dependence on industry funding, however, has drawbacks, as the work can be tedious and also can involve conflicts of interest (IOM, 1994; 2002b; Pincus, 1995). Therefore, such arrangements with industry need to be carefully conceived.

Dr. Pardes and others have also made the point that medical institutions need to work aggressively to raise money for research from private sources, such as foundations and individuals in their community (Jacobs et al., 1997; Pardes, 2002). This notion is supported by public opinion surveys indicating that 61 percent of the population is willing to pay higher taxes to support research funding (Research!America, 2002), as well as by focus group and survey work done by the AAMC revealing that biomedical research and patient care rank well ahead of clinical GME in the minds of most voting Americans (Knapp, 2002). These findings indicate that general departmental fund-raising efforts and those targeting residency or fellowship research training programs are of interest to many potential private donors. In fact, philanthropic support for GME might well benefit from reminding potential donors that today’s residents are tomorrow’s researchers. One example of successful philanthropic fund raising occurred at the University of Texas at Southwestern, where the psychiatry department raised funds to support nine endowed chairs, four additional faculty positions, and $18 million in research activities from 1977 to 1996 (Meyer and McLaughlin, 1998).

Collaboration with other departments or institutions. An alternative way for small programs to tap available clinical research resources is to seek out opportunities for interdepartmental or interinstitutional collaboration. A recent AAMC task force made the following recommendation:

To enhance clinical research programs and infrastructure development, medical schools and teaching hospitals

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

should encourage interdepartmental collaborations, as well as joint efforts and alliances with other units in the university and with external organizations, such as community organizations, HMOs, and other medical schools and teaching hospitals (AAMC, 1999:80).

In a 1998 study of how psychiatry is adapting to the pressures of managed care, Meyer and McLaughlin (1998:84) also advocate a broad collaborative approach:

As individual clinical departments become less able to fund their own essential research infrastructure, medical schools will need to develop institution-wide collaborative efforts to assure access to cutting-edge technology relevant to research on clinical disorders. In this regard, research in psychiatry may be linked to other efforts in clinical and basic neuroscience, human genetics, health services research, clinical trials, and treatment and prevention research relative to general and mental health issues.

Meyer and McLaughlin cite several examples of successful collaborations between researchers lacking critical technology and those having the necessary resources. One such example is Meyer’s experience as chair at the University of Connecticut’s department of psychiatry, during which time an addiction “center without walls” was formed between his program and Yale University’s Department of Psychiatry. Since the center’s formation, principal investigators have come from both the Yale and University of Connecticut faculty (Meyer and McLaughlin, 1998). The University of Connecticut’s current program is described further in the section below on curriculum.

LEADERSHIP AND MENTORING

Institutional Leadership

It is perhaps axiomatic to say that if research endeavors are important to presidents of universities, CEOs of hospitals, and deans of medical

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

schools, research will be important to department heads, training directors, and residents. Many of those who made presentations to the committee—including Herbert Pardes; Paula Clayton, former chair, department of psychiatry, University of Minnesota; and Henry Nasrallah, former chair, department of psychiatry, Ohio State University—made this point (Clayton, 2002; Nasrallah, 2002; Pardes, 2002). Additionally, the literature contains numerous references to the importance of leadership to the research endeavor, psychiatric research, and research training (Katerndahl, 1996; Meyer and McLaughlin, 1998; Pardes and Pincus, 1983; Rosenberg, 1999).

Leaders who value research will likely promote research and research training in the following ways:

  • They will recruit department and division heads who have research experience.

  • They will consider research a major part of their leadership agenda, thereby advancing institutional comprehension of the value of research activity.

  • They will use research success as an important criterion for appointment and promotion, taking into consideration the challenges associated with patient-oriented research.

  • They are more likely to offer research start-up funds and other resources to newly hired faculty so these individuals will have time to prepare competitive applications for extramural funding.

  • They will offer qualified faculty provisions for unfunded release time from other activities (e.g., clinical and administrative) for purposes of initiating or renewing extramural research funding streams. These release time provisions may furthermore be offered to offset the time necessary to teach and mentor trainees and medical students.

  • They will encourage trainees to engage in ongoing or original research projects, and raise and distribute money for capital enhancements to the research infrastructure, including space, equipment, and administrative support personnel (AAMC, 2002b; Ahrens, 1992; Kaplan, 2000).

These executive strategies for research promotion are perhaps obvious, and there is evidence that many leaders in academic medicine appreciate and support the importance of the research enterprise, including clinical research. However, there is also concern that many leaders say they support research on the one hand, but overemphasize the financial bottom line in favor of clinical revenues on the other (Oinonen et al., 2001; Rosenberg, 1999).

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

Departmental Leadership

In addition to support from institutional executives, the department chair’s attitude is critical to fostering research and research training. According to Paula Clayton in her presentation to the committee (2002), the chair has principal authority over professional expectations that include the amount of time devoted by faculty and residents to various activities, including research. To advance the goal of increasing patient-oriented psychiatrist-researchers, the committee believes it is best if department chairs are themselves successful basic or patient-oriented researchers. In lieu of that direct experience, the chair might designate an associate chair who is an accomplished researcher. Having a researcher in a leadership role gives investigative efforts the necessary voice to request department resources and to characterize the importance of emerging knowledge to trainees as well as to the general public.

Although based largely on presentations to the committee by chairs and resident training directors of psychiatry departments, our strong view is that when hospital executives and department chairs view research as a high priority, there is an increased likelihood that research and research training programs—including research-focused didactics, biostatistical and data management support, research options for residents, department-sponsored research fellowships, effective mentorship, and funding for travel to attend national research meetings—will flourish. Empirical support for the importance of leadership is difficult to obtain, but at least one recent study offers validation of the notion that proactive leadership can promote research activity. A study of 351 departments of family medicine (76 percent response rate) found that research activity, quantified by the number of publications and funded grants, increased in large programs (i.e., those with more than nine faculty) that had a strategic research plan and in small programs (i.e., those with nine or fewer faculty) that mandated research activity among faculty members. Comparable increases were not seen in those that did not have such research mandates (Kruse et al., 2003).

In accordance with requirements established by the Psychiatry Residency Review Committee (RRC), accredited training programs must have a residency program director who devotes at least half-time effort to the administration of the residency program (ACGME, 2000b). Training directors typically remain in their position for a very short time: 30 percent vacate their position each year, and most occupy the position for less than 3 years (Balon and Singh, 2001; Batalden et al., 2002; Miller, 2002; Winstead, 2001). Research experience is neither a prequalification nor a common characteristic of the vast majority of training directors

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

(ACGME, 2000b; Dawkins, 2002; Drell, 2002). Given that training directors interact with residents more than do other department faculty, the committee believes the ideal research training program in residency will have an experienced researcher as the training director, although we acknowledge that there may not be enough psychiatrist-researchers to fill that role (Drell, 2002). Alternatively, and in line with the time demands of the program directorship, a researcher can be appointed, perhaps as an associate, to participate in structuring an educational program for residents that will include exposure to practical and theoretical research opportunities. Regardless of exactly how researchers are better integrated into the departmental education effort, encouragement from senior leadership will likely be of critical importance to a program’s ultimate ability to secure resources and motivate trainees to pursue research education and careers.

Mentorship

Mentorship is arguably the most intense and critical form of leadership associated with training in any field. It is one of the most frequently cited components of a successful biomedical research career (Balon and Singh, 2001; Blake et al., 1994; DeHaven et al., 1998; IOM, 1994; Kanigel, 1993; Ledley and Lovejoy, 1993; Lewinsohn et al., 1998; National Research Council [NRC], 1997; Pincus et al., 1995). An IOM report on careers in clinical research notes:

Mentors play a crucial role in stimulating individuals to pursue a particular career path, shaping the content of their training, socializing them in the research environment, and providing support and guidance in the formative stages of their career (IOM, 1994:58).

Several surveys of M.D.-researchers have led to the conclusion that mentoring is one of the most important influences on career choice for potential physician-investigators (Balon and Singh, 2001; DeHaven et al., 1998; Levey, 1992; Levey et al., 1988; Pincus et al., 1995; Shapiro et al., 1991). A survey by Pincus et al. (1995), for example, found that more than 95 percent of respondents cited time with a mentor as an extremely important part of their research training, more important than other training components assessed. And a survey of 20 psychiatry residency training directors found that “the one point on which there was general agreement was that the most important way of interesting a resident in

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
×

research is to provide successful experience with a research mentor” (Rieder, 1988:288).

Several participants at the committee’s workshop on obstacles to research training (see Appendix A) spoke of the importance of mentors and the scarcity of time for researchers to serve in that role. Martin Drell of Louisiana State University (former president of the American Association of Directors of Psychiatry Residency Training [AADPRT]) said that residents look to their training directors and clinical supervisors, who are nonresearchers, for inspiration. Furthermore, he added that researchers typically do not spend time with medical students or residents:

If you are truly serious about being a researcher, you eschew everything else, such as teaching, to become totally focused on your research career….As you get more successful in research, you remove yourself more from the very population that could probably benefit from your inspiration.

At the committee’s September 2002 meeting, Daniel Winstead, chair, department of psychiatry and neurology, Tulane University (recent chair of the Psychiatry RRC, current member of the board of directors of the American Board of Psychiatry and Neurology, and president of the American Association of Chairs of Departments of Psychiatry), was even stronger in his assessment of the lack of interaction between researchers and nonresearchers in psychiatry. He suggested that researchers and nonresearchers in psychiatry exist in “different worlds” that include different organizations, meetings, committees, and faculty tracks (Winstead, 2002). As psychiatrists in their formative years tend to gravitate toward one world or the other, and as there are few patient-oriented researchers in psychiatry, these professional differences limit opportunities for potential researchers to meet and pair with suitable mentors.

In his presentation to the committee, Roger Meyer, a psychiatrist and senior consultant for clinical research at the AAMC, summarized the situation as follows: “Most medical students and residents are not being systematically exposed to high-quality clinical research or role models and mentors as part of their professional development” (Meyer, 2002).

The current lack of psychiatrists in the academic community who specialize in child and adolescent psychiatry makes the shortage of suitable mentors for residents in that subspecialty especially acute. According to a study by the AADPRT, child and adolescent programs are small

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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(75 percent have six or fewer faculty), and nearly half of those programs have problems recruiting high-quality faculty (Beresin, 1997; Beresin and Borus, 1989). Special efforts must be made to address mentorship in child and adolescent psychiatry programs. Moreover, given the shortage of child and adolescent psychiatrists serving as research mentors, departments should develop mentoring arrangements between child and adolescent trainees and faculty in other divisions and departments.

Recognizing the importance of mentoring early in a resident’s training, the Western Psychiatric Institute and Clinic’s (WPIC) department of psychiatry provides a network of mentors to residents early in their training. By providing more than a single mentor to each trainee, this system increases the probability that suitable mentor matching will occur during the residency period. For example, some faculty may mentor students on how to find a suitable mentor or project, whereas others may ultimately offer the trainee an individualized research education (Pincus, 2001a; 2002; Swartz and Cho, 2002). While such multitiered mentoring requires additional faculty and is potentially redundant, the committee believes it represents a wise approach given the complex interpersonal and scientific issues than can underlie the formation and maintenance of the mentor–trainee relationship (Kanigel, 1993).

At present, psychiatry appears to be open to broad sources of mentoring, including joint mentoring by junior and senior faculty and the use of visiting or even remote professors as mentors (Lewinsohn et al., 1998). Psychiatrists also depend heavily on Ph.D. mentors, as psychologists (including many clinical psychologists) and other non-M.D. doctorates represent nearly 60 percent of NIH-funded investigators in departments of psychiatry (Meyer, 2002).27 Indeed, the shortage of mentor time is considered so acute that for smaller programs, remote or telementoring might be an effective remedy. An example of how such remote mentoring can be accomplished is provided by the Service Corps of Retired Executives (SCORE), a nonprofit association of 11,500 volunteer business counselors. The association provides e-mail counseling to “aspiring entrepreneurs” and especially targets small-business owners (SCORE, 2003). The American Psychiatric Association colloquium (APA, 2003), the minority mentoring network (National Advisory Mental Health Council’s Workgroup on Racial/Ethnic Diversity in Research Training and Health Disparities Research, 2001), and a summer seminar series in geriatrics (Halpain et al., 2001) are three programs in psychiatry that

27  

In 1999, 59 percent of NIH grant awardees in departments of psychiatry held a Ph.D. degree. By comparison, Ph.D.’s in internal medicine departments hold 24 percent of that discipline’s NIH grants.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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could form the foundation for a SCORE-like mentoring network or some other national project to connect trainees to mentors. Although remote mentoring would likely prove to be far inferior to in-person training, it might nevertheless foster collaborations between senior and fledgling investigators that would otherwise not occur. It might also ignite research careers among some talented trainees.

Despite the widely acknowledged importance of good mentoring, there are strong financial and time obstacles to faculty members’ mentoring of residents, fellows, and junior colleagues. Medical school faculty members are expected to account for their time in generating the bulk of the funding for their salaries. Most faculty costs associated with research training and mentoring must be subsidized either by the sponsoring institution or by the faculty member’s taking time from other funded activities. The latter strategy is problematic given increased scrutiny and accountability for the allocation of federal resources. In addition, as a result of increased clinical loads, lower clinical revenues, and/or the general demands of research, many academic clinicians have difficulty finding the time to mentor. As noted by the AAMC Task Force on Clinical Research (1999:63), reduced time for mentoring is coupled with lower revenues from clinical work:

Faculty practice and affiliated hospital revenues have been major sources of discretionary funds for the subsidy of research….As pressures have mounted to sustain clinical income on lower rates of reimbursement per patient, faculty in these departments have difficulty accessing time for research and research mentorship.

For those departments with solid funding and a supply of talented trainees, trainees serve as much-valued junior colleagues. For smaller programs and those with a limited supply of trainees or resources, training a new researcher may initially require a considerable expenditure of time with little gain. It has been suggested by some established researchers that one way to counter the lack of funding for mentors is to provide supplemental funding to senior investigators who commit time to mentoring young investigators (Lewinsohn et al., 1998; Meador-Woodruff, 2002). Such piecewise funding may be especially relevant to research progress at institutions with limited resources and to trainees who have little or no research experience. There is at least one grant mechanism—the federally funded Midcareer Investigator Award in Patient-oriented Research (or K24 grant)—that explicitly funds established investigators

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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to develop their skills as clinical researchers and as mentors. This award, which has a duration of up to 5 years, allows clinical researchers 50 percent time to develop these skills. NIH funds 60 to 80 K24 awards each year (NIH, 1999c). In general, however, salary support under research and training grants does not include mentor salaries because of the philosophy that (1) teaching is compensated by the productivity of the trainee, and (2) teaching is part of the core responsibilities of an academician and of their sponsoring institution. Given the shortage of mentors and the fact that many mentors have time constraints secondary to increased service requirements, it appears logical to the committee that a broader array of support mechanisms is needed to make mentoring a more frequent part of residency training.

PROGRAM AND CURRICULUM STRUCTURE

Central to a program’s ability to train researchers are the structure of the departmental milieu and the training curriculum. This section explores those elements in four ways. First, it reviews existing literature that describes various clinical training programs both within and outside of psychiatry. Second, it describes five illustrative training models, drawing on a combination of the published literature and communications between the committee and program faculty. Third, it presents the views of eight department chairs whose programs the committee believes can be characterized as emerging with regard to their overall research effort and exemplify various strategies and ideas for enhancing research training options in residency training. Finally, it details informal information gathered from several child and adolescent psychiatry divisions that characterizes the issues they face regarding research.

Published Reports on Research Curriculum Design

A number of publications address clinical research training both within and outside of psychiatry, but only a small number of these reports focus on residency; even fewer consider program success by offering substantive outcome data (i.e., information about how effective the program has actually been at training productive researchers). The absence of solid literature on research training in residency is likely related to the reality that medical educators are typically trained as medical doctors, and focus first on content rather than on established educational methods (Sheets and Anderson, 1991). Nevertheless, there are some worthwhile publications addressing research training in clinical research broadly and in psychiatry more specifically. Some of these works are

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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reviewed below. It should be noted that these publications represent an illustrative sampling rather than a systematic review of all existing literature on the subject. This sampling emphasizes clinical research training for all M.D.’s generally, and especially for potential psychiatrists. All the works reviewed are from the last 10 years.

An excellent summary of existing training programs was produced by the AAMC Task Force on Clinical Research (1999). This summary describes 16 illustrative programs to demonstrate the range of contexts and issues that relate to clinical research training. A majority of programs lead to masters or Ph.D. degrees, although a small number are short-term (e.g., summer programs). The fact that these programs are so variable in length led the task force to conclude that the optimal length for clinical training is unclear. All programs place a high value on intensive, hands-on training in conjunction with requisite coursework. Common core training courses include biostatistics, epidemiology, grant writing, and design and methodology of clinical trials. Mentored research is noted as a key component of these programs. Funding for salaries (of trainees and mentors), tuition, and administrative costs are key constraints on program size and effectiveness. Trainee recruitment at most institutions is not considered a major problem. Instead, “converting…[potential trainee] interest into a solid career choice” is viewed as a greater challenge. Finally, these descriptions do not identify programs that integrate research training into conventional residency, although they encompass options that couple subspecialty training with a Ph.D. in clinical investigation (e.g., The Johns Hopkins University’s Graduate Training Program in Clinical Investigation), a part-time masters degrees, or “time out” from residency options.

An important model described by the AAMC task force is the NIH Clinical Research Curriculum Development Award (or K30 grant) developed in response to a 1997 NIH report on clinical research (known as the Nathan Report). This grant offers support for the creation of clinical research training curricula for postdoctoral-level trainees across disciplines (NIH, 1997b). Wide latitude is given to the institution to develop a curriculum that suits its local needs, but a typical implementation resembles a 2-year masters degree. As the program is new, no evaluation has yet been done, and it is not clear how long the program will continue (personal communication, L. Friedman, NIH, April 17, 2003). Nevertheless, the K30 is relevant to residency-based research training because it encourages the development of clear educational goals related to general clinical research training. As of April 2003, an informal e-mail posting to 57 K30 program directors had yielded a response from 21 programs, reporting a total of 556 trainees. Those programs all indicated that they

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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were designed to accommodate full-time fellows and junior faculty; thus, only 2 percent of the trainees were residents, and 1 percent were psychiatrists. Low resident utilization of existing K30 grants suggests that psychiatry departments need to increase their trainees’ awareness of the K30 program at their institution. It may further suggest that few if any implemented K30 programs have been designed to accommodate the intense schedules to which residents must adhere.

A systematic literature review by Hebert et al. (2003) identifies 41 publications focused specifically on residency-based research training among different specialties. The search criteria included only published curricula describing local programs that target research training for residents. Hebert et al. found only a single program designed to produce academic physicians, suggesting that most programs are directing their research training efforts to all residents rather than to the training of independent physician-investigators. The authors further note that evaluation procedures are used infrequently: only 12 percent of the publications include some objective measures of pre- and postintervention research skills or accomplishments, and none include long-term follow-up.

The obvious conclusion one can draw from Hebert et al.’s review is that, somewhat ironically, literature on research training is not very scientific. It does, however, provide anecdotes and knowledgeable opinions regarding frequently endorsed goals and obstacles to research training. Given the earlier discussion in this chapter, it is not surprising that lack of time and money are key barriers noted explicitly in 7 of the 41 publications. Additionally, with regard to mentoring, 6 articles cite lack of faculty experience in supervising residents in research as a barrier. Somewhat surprising is the fact that resistance from residents is identified as an obstacle to research training in 8 articles. Key goals cited most frequently are attaining competency in critical review of research findings (13 articles) and increasing the actual scholarly activity of residents (14 articles).

In January 2000, Balon and Singh surveyed 126 academic departments of psychiatry in North America with a brief (30-item) questionnaire aimed at research training (2001). The survey yielded a modest response rate of 59 percent, in part because the subject matter likely elicited a higher proportional response rate from research-intensive training programs than from more clinically oriented programs. Aggregated findings include the following percentages that summarize the status of research training in psychiatry. Of the 70 responses received, just under a third of the programs have a research track, and for 87 percent of those programs, fewer than one in four residents enter that track. A high proportion (91 percent) of all programs have a research elective month,

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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which is typically offered in PGY3 or PGY4 (78 percent of the time). Fewer than half of the programs (42 percent) offer a research fellowship. Nearly all the programs (91 percent) offer a research course to residents, most typically in PGY2 (48 percent). This research coursework usually accounts for less than 6 percent of the entire curriculum. Courses in research design are rarely part of the didactic (28 percent), and although most programs provide the “opportunity” for residents to join a research project, in 73 percent of the programs, fewer than 25 percent of the residents actually do so. Overall, the survey led the authors to conclude that research didactic learning and activity in academic psychiatry departments of North America are insufficient.

Several recent articles review local efforts to increase research training among residents. Clayton and Sheldon-Keller (2001) describe a weekly 1-hour mandatory seminar for PGY2 residents that involved group engineering, implementation, and research/writing of a modest research project. Between 1994 and 2001, 30 residents took part in the seminar. Satisfaction ratings were favorable, although not outstanding, and simple pre- and post-testing of 13 to 14 residents indicated that they had gained research knowledge from the experience. The authors note the value of linking short-term activities to the formal process of conveying scientific results to the outside community of scientists (e.g., literature searches and reviews are conceptually linked to the production of manuscript or grant “background” sections).

Paniagua et al. (1993) describe a weekly 2-hour research seminar, during which child and adolescent psychiatry residents reviewed case vignette modules that included a list of pertinent research questions. The philosophy behind this training was to emphasize the relevance of research to the future development of psychiatric practice. Of the 14 trainees who participated in the program from 1989 to 1991, 8 developed research projects, and 5 became academicians (Paniagua et al., 1993). Paniagua et al. also emphasize the importance of translating research material into a language that is readily comprehensible to individuals with clinical medical training.

Lambert and Garver (1998) describe a program for mentoring of medical students and psychiatric residents in publishing a scientific paper. They suggest that such a program is of central importance to effective research training based on the premise that publishing a paper is “one of the most rewarding experiences in academic life…” (Lambert and Garver, 1998:47). They also stated that the program was implemented in 1992 despite skepticism by many faculty who “had reservations about investing large amounts of time and energy if most residents were unenthusiastic about the endeavor” (Lambert and Garver, 1998:48). As an

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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index of the program’s success they report that by 1995 eight papers were produced by an equal number of residents. These papers ranged from case reports by junior faculty to a formal empirical study by a fourth-year resident on a 9-month research track.

Pato and Pato (2001), former faculty at the State University of New York at Buffalo (currently at the State University of New York at Syracuse), describe a seminar consisting of 12 1-hour lectures designed to teach psychiatry residents the process of research. The first 8 lectures were aimed at various types of study designs (e.g., case-control); the last 4 focused on research writing and publishing. At the end of the seminar, all participants submitted a “letter to the editor.” Outcome data using pre-and postseminar measures to assess subjective (i.e., self-assessment) and objective gains in research knowledge were favorable, although the practical impact of the work product was more limited: of 74 participants in the seminar, 68 had submitted letters to the editor, but only 13 of those letters had been published (Pato and Pato, 2001). More important, no data are presented about the career paths since taken by the seminar participants. Nevertheless, this intervention is notable for its portability, as it is adaptable to various topics in psychiatric research, and the authors themselves have implemented the program in at least two other institutions besides their own.

Kirchner et al. (1998) describe a departmental effort to increase research activity among residents at the University of Arkansas for Medical Sciences. The system utilized a block rotation through multiple affiliated training sites, including the Central Arkansas Veterans Healthcare System, the state psychiatric hospital, and affiliated outpatient clinics. Most of the sites offered residents the opportunity to join ongoing research activities. These arrangements included a research training option that provided at least 1 half-day of protected research time and 1 hour of supervision per week. The department also established a standing committee of faculty representatives, including the residency training director, to oversee residency-based research activities and to review residents and faculty involved in these research training arrangements. Other general features of the program included a formal assessment of PGY1 residents’ knowledge and interests regarding research, and PGY3 and PGY4 rotations in an outpatient clinic that included an ongoing research effort in depression treatment outcomes. As an index of the success of the overall program, the authors note that resident-authored abstracts and resident research activity have since increased. More specific or long-term assessment of participants is not reported.

A number of common themes emerge from the above literature review. First, the timing and duration of clinical research training are quite

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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variable. Some programs offer Ph.D. degrees, others masters, and others only an isolated experience with no formal certificate. Generically, clinical research programs offer instruction in biostatistics, epidemiology, paper and grant writing, clinical trials design, and research study critiquing skills. Research training across medical residencies is limited by time and the desires of many residents who presumably are focused on completing their clinical training. Nevertheless, many programs are striving to increase scholarly activity among their residents. Research training exists within psychiatric residency, but intensive research training in the form of research tracks appears to attract fewer than 9 percent of residents (Balon and Singh, 2001). For the successful programs that do exist, only limited data are available on the long-term effectiveness of their efforts (i.e., the career research productivity of their trainees).

Illustrative Programs

This section describes five illustrative programs that appear to have amassed exceptional research-related resources. The programs of Columbia University, WPIC, and the University of Michigan are included because they have been recognized as illustrative research training programs by NIMH and APA. The committee wishes to note that a description of the University of Michigan’s program is retained despite the fact that one of the committee members is from that program. Michigan’s program, however, is described because it offers a useful example of how intermediate-sized programs can foster research training efforts. The University of Connecticut’s program was also selected because it represents an intermediate-sized program with a developing research training effort. Finally, the NIMH PGY4 program is highlighted because of its connection to the world-class biomedical research environment of NIH. As noted earlier, these five programs should be considered a sample of convenience, used by the committee to detail the current state of research training by highlighting those programs that, at least by reputation, appear to be succeeding in their research effort generally and by extension at research training. These five programs should not be taken as an exhaustive list of high-quality or up-and-coming research training programs in psychiatry, as there clearly are other successful programs not described here, including those closely affiliated with the committee members authoring this report.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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Columbia University

One of the largest psychiatric residency research training programs is that of the New York Presbyterian Hospital and the New York State Psychiatric Institute (NYSPI). The program is administered by Columbia University’s department of psychiatry, a department that is closely coupled with numerous research efforts at Columbia and the NYSPI. These research efforts include a neurobiology division directed by Nobel laureate Eric Kandel and the Center for Psychoanalytic Training and Research, established in 1945, the first such alliance between psychoanalysts and a university in the United States. The program’s curriculum and overall environment are detailed on the department’s website (Columbia University, 2002), and its research training philosophy was recently featured in an issue of the APA’s Psychiatric Research Report (Rieder, 2003).

The core didactic curriculum includes approximately 525 hours of instruction distributed across PGY2 through PGY4 (Columbia University, 2002). The didactics are dominated by clinical training. Only in PGY4 is there formal instruction in psychiatric research and in “journal reading,” amounting jointly to 13 hours of classroom time. The strong implication of such a curriculum is twofold. First, psychiatric educators at Columbia University believe that the mastery of clinical knowledge, ranging from psychopharmacology to psychotherapy, should dominate the early core didactic curriculum of the psychiatry residency. Second, researchers who emerge from Columbia’s residency program do so in large part because of longitudinal experiences that occur outside of the didactic curriculum. The residency program, for instance, places some PGY1 residents in the schizophrenia research unit for 3 months and all PGY2 residents in a research unit for nonpsychotic disorders for 4 months. Residents also have opportunities for research work with a “preceptor” during PGY2 and PGY3 and up to 8 months of elective research in PGY4. Finally, all residents are required to conduct an independent study project that may include preparing a research paper for publication (Columbia University, 2002).

These residency program components suggest an implicit research track for at least some residents, although it is notable that Columbia recently discontinued its formal research track in favor of encouraging all residents to pursue research experiences (personal communication, R. Rieder, Columbia University, March 29, 2003). Ultimately, however, Columbia’s residency training aims to educate the next generation of psychiatrist-researchers by encouraging residents to extend their training to a 2- to 4-year research fellowship. These fellowships, mentioned pre-

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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viously, offer intense training in nine different topic areas (e.g., substance abuse, schizophrenia, child psychiatry), and stipends are supported with training funds from NIMH (T32) and the state. Data for 1989 to 1998 suggest that 60 to 70 percent of fellowship graduates in schizophrenia and affective disorders maintained careers as researchers by obtaining either an early mentored career (K) award (45 percent) or other full-time support for their academic efforts (24 percent) (Rieder, 2003). It is also notable that female and minority graduates from these fellowships have been successful in sustaining research careers at rates comparable to those for men and nonminorities (Rieder, 2003). For residents, however, research career tracking is less common, as only 56 of 184 graduates (or 30 percent) from 1985 to 1999 moved on to research careers (personal communication, R. Rieder, Columbia University, April 10, 2003).

Western Psychiatric Institute and Clinic

WPIC in Pittsburgh is the leading psychiatry department in terms of total funding received from NIH. In fiscal year 2002, it received nearly $78 million in federal funding (NIH, 2003b). As is the case with the Columbia residency, most lecture and seminar time is devoted to clinical issues, although there is an “advanced literature seminar” in PGY3 (WPIC, 2002a). The implication once again is that dedicated research training courses are not typical, even in a research-intensive program. Yet while research is not necessarily central to lectures and seminars, residents at WPIC likely obtain research exposure because of the research culture that exists at the institution. The department chair is David Kupfer, and his commitment to psychiatric research and research training is well established (Kupfer et al., 2002; Meyer and McLaughlin, 1998). Indeed, the values of departmental leadership have been noted as supremely relevant to the institution’s successes in overall research activity (Pincus, 2002). Mentoring, also said to be key to WPIC’s success, is made possible by the “critical mass” of researchers: the department has more than 100 faculty principal investigators (WPIC, 2002c). There is also an incentive for mentoring in that success in the activity is a significant criterion for promotion (Swartz and Cho, 2002). The importance of the interpersonal aspects of research training is further emphasized by monthly dinner meetings of trainees and senior faculty that typically occur at the vice chair’s home.

As noted earlier, trainee research activity at WPIC has been linked conceptually to research training experiences before and after residency (see Table 2-1 in Chapter 2). This linkage is characterized as a “series of bridges” that help psychiatric trainees deal with the path from medical

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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school to independent investigator status (Swartz and Cho, 2002). As with the program at Columbia, several T32 fellowships are available at WPIC. Additionally, there is an R25 grant (see Appendix B for a brief description) that supports junior faculty time for grant preparation, as well as seminars in research survival skills targeting residents, fellows, and junior faculty. Entry into the research track in residency is informal, and about 50 percent of the residents who enter the research track do so at the beginning of their residency with others joining the track later during their training. Because of the clinical responsibilities in PGY1 and PGY2, research-related activities are held until the last 2 years of the adult residency and can involve as much as 50 percent time in PGY3 and nearly full time in PGY4. Outcome data indicate that from 1996 to 2001, at least 14 of 68 (21 percent) of graduating residents became research fellows (personal communication, N. Ryan, WPIC, April 16, 2003), and 11 of 17 R25 trainees from 1999 to 2002 received career awards (Swartz and Cho, 2002).

University of Michigan

Somewhat smaller than the programs at Columbia and WPIC is that at the University of Michigan. While Columbia and WPIC took in a combined $97.5 million in federal grant funds in 2002, the University of Michigan took in $9.6 million (NIH, 2003b). Nevertheless, Michigan’s program is one of the models to which the psychiatric community has turned in the past few years in considering ways to enhance the integration of research training into the psychiatric residency. The Psychiatry Department at Michigan is well connected to efforts to enhance psychiatric research, as the chair of that department, John Greden, is also chair of the APA’s Council on Research (see Chapter 3 for more detail).

The University of Michigan’s model for research training in residency extends the 4-year adult psychiatric residency to 5 years so that the last 3 years of that training can include approximately 50 percent time for research activity (McCullum-Smith, 2002). This program was recently funded by an NIMH Mental Health Education Grant (R25) to cover the costs that are not encompassed by Medicare funding for residency training (NIH, 1999a). The program includes one or two 1-month research blocks in PGY2 to give residents some protected time to initiate their research projects. According to the vice chair for research at the University of Michigan, James Meador-Woodruff, as of November 2001, 90 percent of all graduates of this research track had moved on to research careers (Meador-Woodruff, 2001). Additional outcome data have not been obtained.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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University of Connecticut

The program of the University of Connecticut’s department of psychiatry, like that of the University of Michigan, is relatively small. The department received $4.6 million in NIH research funding in 2002, ranking forty-first among departments with regard to such extramural funding (NIH, 2003b). The department includes three prominent research centers: the Alcohol Research Center; the Neuropsychopharmacology Treatment, Research, and Training Center; and the Center for the Study of High Utilizers of Health Care. From 1997 to 2001, extramural research funding to the department increased from $7 million to $10 million, with most of that funding coming from the federal government and most being directed toward patient-oriented research.28 The number of physician faculty members conducting research increased from 5 in 1997 to 12 in 2002. Within the entire 31-member department faculty, there have been 16 R01’s and several career awards, one of which is described below.

Residents may pursue training in the 4-year adult residency program, subspecialty training in the 5-year child and adolescent psychiatry program, and/or a 1-year fellowship in clinical addiction psychiatry (begun in 1999 with funding from the National Institute on Alcohol Abuse and Alcoholism [NIAAA]) or a 2-year fellowship in psychopharmacology (begun in 2000) (University of Connecticut, 2002). Residents and other clinical investigators may also receive training in treatment outcomes for adolescents with alcohol or substance abuse problems under the supervision of Yifrah Kaminer, M.D., who received a K24 grant in 2002 from NIAAA. Those selected for this training program are provided general guidance and encouragement and are taught research methodology and data analysis (NIH, 1999a; University of Connecticut, 2002).

There are a number of seminars in each postgraduate year from which residents may choose, including several that focus on research methodology, clinical trials, informed consent, and ethics. Approximately 15 percent of the seminars offered deal with research and research-related issues. Additionally, PGY1 residents are rotated individually through a 1-month exploration of department research activities with no clinical obligations. Finally, a research requirement was initiated in 2001 whereby PGY1 residents attend a “research fair” that showcases departmental research, select a faculty mentor, conduct research during PGY2 through PGY4, and present findings during the Annual Research

28  

Unless otherwise indicated, data in this section were obtained through extensive personal communication with the department chair, Dr. Leighton Y. Huey.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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Day. These programs appear to be steering more medical students and psychiatric residents toward patient-oriented research.

National Institute of Mental Health PGY4 Program

A survey of residency-based research training would be incomplete without including a program that is administered intramurally by NIMH, given that this program should have the best resources and students (NIMH, 2002b; 2002c). NIMH PGY4 program residents assume responsibility for the evaluation and clinical care of inpatient and/or outpatient research subjects at the state-of-the-art Warren Grant Magnuson Clinical Center. They also receive training in clinical research design, methodology, statistical analysis, and administration (e.g., funding, monitoring). In 2002, six adult and two child and adolescent psychiatry residents participated in the program. The program targets the most talented psychiatric residents in the country and aims to give them specialized training in biological psychiatric clinical research. It is not known how successful graduates of this program are at future research endeavors, as the program does not systematically follow the participants after graduation (personal communication, B. Kaplan, NIH, July 29, 2002).

Common Themes

One important theme that can be extracted from the above program descriptions is that there is typically a modest amount of research training in PGY1 and PGY2, with the exception of clinical rotations in research units (if they exist) and research-oriented didactics, which are likely to represent well under 10 percent of the resident’s time. Some programs have a research track that offers a special curriculum for selected students, but Columbia recently moved to a system that encourages all residents to pursue research through a core curriculum and electives. A rich supply of faculty, incentives for mentors, and supportive leadership all have been cited as important ingredients in the success of the above programs. Noted curriculum content includes the usual subjects of biostatistics, research methods, journal clubs, and research management.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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Other Aggregate Program Data

Emerging Programs

In an effort to further understand local factors that influence residency-based research training, IOM staff interviewed eight department chairs. These eight chairs were selected because one or more committee members believed their departments were emerging or up-and-coming with regard to interdepartmental research activity. Thus the list of departments selected is representative rather than exhaustive. Furthermore, while these programs appear to be emerging with regard to research activity generally, they have achieved varied success in research training for residents. A list of those interviewed appears in Appendix A.

Unfortunately, these interviews yielded no novel solutions for the research training problem. However, several potential strategies were reinforced by the responses obtained. Specifically, all chairs were asked whether they had any unique strategies for recruiting research-minded residents and faculty. No such strategies were reported. Instead, responses were fairly predictable, with some of the chairs reporting that, while they liked to recruit researchers, research experience was only one of several selection criteria utilized. Several of the chairs noted that research start-up resources were often used as an incentive to attract prospective faculty.

As for research training specifically, all eight department chairs said they had research didactics, six of eight had discretionary funds for research activity, and five said they had a designated faculty member responsible for monitoring research activity within the department (e.g., vice chair for research). Most of the programs had some formal mentoring component, while only four chairs said they had a formal research track, and three said they required residents to take part in research activity.

When asked about obstacles to research training during residency, the majority of chairs stated their belief that limited funding, mentors, and time were key constraints. Nearly all (seven) chairs said that the shortage of child and adolescent psychiatry researchers was especially acute. A majority (six) of the chairs also said that program accreditation requirements limited research training opportunities in residency. However, the perceived magnitude of this limitation was quite variable among the chairs: one felt the requirements enhanced research training, whereas another was vehement that the requirements were inappropriate and excessive. Only one or two chairs believed that any of the following issues were significant barriers to research training in residency: educa-

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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tional debt, competition from Ph.D. investigators, clinical faculty not valuing research, attitude of training director, or lack of interest among residents. Appendix C and Table 4-2 provide some additional detail on the eight emerging programs whose chairs were interviewed, along with other programs reviewed by the committee.

Child Psychiatry Programs

Finally, to understand residency-based research training issues in child and adolescent psychiatry, the committee contacted Robert Hendren, D.O., president of the Society of Professors of Child and Adolescent Psychiatry (SPCAP). SPCAP is a professional society composed of directors of child and adolescent psychiatry programs, many of whom have research experience. Dr. Hendren solicited responses via e-mail from the SPCAP membership to the following questions: (1) Does your institution offer a credible research training course? (2) What would it cost to have a trainee spend 4 hours per week engaged in research training during the 2-year residency program? (3) What would it cost to compensate the “mentor”? and (4) Should research be mandated for trainees? Finally, respondents were asked to state their general opinions about research training and to provide information about where their residents ended up after graduating from the residency program.

Of the 116 child and adolescent training programs represented by SPACP members, Dr. Hendren reported a response rate of 25 percent. Despite that low rate, those who responded appear to represent a reasonable cross section of all programs with regard to size and academic orientation, although other, more obscure response biases remain unknown, making the results potentially idiosyncratic to this subsample. Nevertheless, the results are reported here as at least one window into the structure of child and adolescent psychiatry training.

The responses can be summarized as follows. Nine programs (31 percent) offer courses in research methodology and statistics during residency, although most of those courses are poorly attended. Six additional programs (21 percent) have a more practical course, with either a journal club or some kind of evidence-based teaching. When these courses are associated with food (e.g., if lunch is provided), they are better attended. Regarding the generation of a research product, nine programs (31 percent) require trainees to produce a paper or to present a case at grand rounds. Eight programs (28 percent) were in the process of rethinking their research training didactic at the time of the survey. Respondents

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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have no well-formulated method for evaluating their training program in terms of knowledge gains or research productivity.

Several respondents indicated that there are two main components to the cost of research training: the direct inputs into the training, such as teaching time and equipment/facilities, and the costs associated with losing coverage in the clinics that residents typically staff. Respondents who estimated the costs associated with providing 4 hours per week of research training calculated that doing so would require additional funding of at least $5,000–$10,000 per trainee per year, plus $100 per hour to offset the costs associated with individual mentoring. Divisions with substantial extramural research funding may allow residents to assist with an ongoing study offering direct, but supported, research experience. Even resource-rich divisions, however, may not have the funds to support the ancillary activities (e.g., statistical analysis) required to successfully append a question to an existing research study. Respondents from small programs especially noted the shortage of mentor time as a limiting factor in research training.

Most respondents said that the majority of their trainees did not appear to be interested in research education, basing this conclusion on residents’ poor attendance at the research courses offered. Consistent with that evidence, respondents from all levels of programs agreed that research activity in residency should be elective, not mandatory. Furthermore, many respondents suggested that recruiting interested and talented trainees to such research electives was a key challenge that should be addressed with at least two principal strategies. One strategy is to entice junior residents to research training as early as possible in their career, perhaps by formulating an exciting, nationally applicable curriculum in the integrated neural and behavioral sciences. Another strategy is to educate smaller programs about the numerous research training opportunities that exist (e.g., federal and foundation grants, new technology) through seminars, Internet sites, and other outreach methods.

As briefly mentioned in Chapter 3, the principle professional society for child psychiatrists, the American Academy of Child and Adolescent Psychiatry (AACAP) has already made progress in developing model curricula for a “traditional” (i.e., 5-year) residency in adult and child psychiatry and for a 6-year program aimed at “the development of outstanding candidates who are interested in pursuing a career in academic child and adolescent psychiatry” (AACAP, 2003b:2). Both curricula offer a weekly 1.5-hour research seminar beginning in PGY2, research electives of 2 months’ duration in PGY3, and research activity beginning in PGY4. For the traditional track, 1 day is set aside for research in PGY4 and 3 days in PGY5. In the 6-year track, 80 percent of time in

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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PGY5 and PGY6 is dedicated to “mentored research.” The program is being developed in collaboration with a number of stakeholders in psychiatry (including the Psychiatry RRC), and it will soon be implemented at Yale University (personal communication, J. Leckman, Yale University, April 4, 2003). Finally, the AACAP curricula are intended to serve as models for programs nationally. Barriers to broad implementation of such curricula include resident stipends beyond PGY4 (see the earlier discussion of GME funding) and the local availability of research mentors and other patient-oriented research resources.

Program Success in Training Researchers

The committee had neither the resources nor the mandate to gather or generate outcome data on a large sample of residency training programs; however, several programs voluntarily provided some limited data indicating the numbers of researchers that have emerged from their training programs. The data are of limited utility because they were not collected in a systematic fashion. Specifically, they do not represent a random sample of programs, and the resulting success rates are not necessarily comparable across programs. Additionally, it should be noted that most programs do not aim to train psychiatrist-researchers, but instead focus on clinical training, so it is unreasonable to expect that a sizable proportion of their trainees will end up on research career paths. Nevertheless, these data are presented in Table 4-2 to offer a summary view of research training rates across core residency programs (i.e., not a specialized research track).

Despite the imprecision of the data collected, the numbers in Table 4-2 demonstrate that most residency programs yield career researchers well under 10 percent of the time. The difficulty encountered in obtaining these data—many programs provide only estimates—underscores the fact that residency-based research training is not typically monitored. As expected, the proportion of residents who end up in research careers is well below the proportion of research fellows who do so (see the above descriptions of the Columbia University, WPIC, and University of Michigan programs), again indicating the relevance of postresidency training for psychiatrists truly interested in research.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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TABLE 4-2 Research Training Outcome Data from Several Residency Programs in Psychiatry

Psychiatric Residency Program (adult and child together unless noted)

Percentage of Residents Moving into Researcha

Time Period

Brown University

5.0

1997–2002

Columbia University (adult)

30.0

1985–1999

Duke University (child)

7.5

1992–2002

Emory University

10.0

1997–2002

Indiana University

36.0

1997–2002

Johns Hopkins University (child)

36.0

1997–2002

Medical College of Ohio (child)

0.0

1977–2002

North Dakota University (adult)

0.0

1980–2002

State University of New York– University of Buffalo (child)

0.0

1999–2002

University of Arkansas

12.5

1997–2002

University of Connecticut

10.0

1996–2002

University of Michigan (adult)

19.0

1982–2002

University of Minnesota

10.0

1997–2002

University of Nebraska

2.0

1997–2002

University of Texas at Southwestern

5.0

1997–2002

Neuropsychiatric Institute, University of California, Los Angeles (child)

13.0

1997–2002

Virginia Commonwealth University

5.0

1997–2002

Washington University (adult)

14.0

1998–2002

Washington University (child)

23.0

1992–2002

Western Psychiatric Institute and Clinic

21.0

1996–2001

NOTE: aA rough index of the proportion of residents in a given program who move on to research careers. In some cases, this may mean they have been in research careers for several years; in others, it may mean they have recently transitioned to a fellowship or junior research position. Because these values were not obtained systematically, they are intended only as approximations, not as values for comparison across programs.

SOURCE: Data were derived from various sources, including correspondence with training directors, website and literature reviews, and eight focused interviews with department chairs. Appendix C offers additional details regarding the programs listed.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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A crude comparison of the responses in this table with other research involvement rates among psychiatrists confirm the accuracy of the numbers represented. For example, metafile data from the American Medical Association (AMA) indicate that 2 percent of all practicing psychiatrists in the United States consider research their dominant professional activity (Pasko and Seidman, 2002). Likewise, APA survey data reviewed by economist Douglas Schwalm (2002a; see Chapter 5) indicate that just under 20 percent of psychiatrists engage in any (i.e., greater than 1 percent effort) research activity. Accordingly, meaningful levels of research activity by U.S. psychiatrists likely fall somewhere between 2 and 20 percent, suggesting that the numbers in Table 4-2, which average out to 13 percent, are reasonable, but likely include those who dedicate well under 50 percent of their professional effort to the research endeavor. The data in Table 4-2 may further be used to support the hypothesis that the majority of new researchers in psychiatry are trained at a small number of programs as only 5 of the 20 programs represented claimed that 20 percent or more of their residents moved into research careers.

CONCLUSIONS AND RECOMMENDATIONS

This chapter has described institutional, departmental, and curricular factors that influence research training in residency. Funding, mentoring, and resident scheduling issues appear to be the chief constraints on research training in residency. Funding for residency training is heavily influenced by Medicare GME policies, and that funding stream is under increasing negative pressure. Research is not generally considered part of core residency training. As a result, funding for research activity needs to be justified independently and obtained either from extramural grants or from discretionary internal funds (e.g., endowments, profits from practice plans). Leaders of medical institutions have control over how Medicare and other funds are distributed. They additionally set expectations regarding trainee and faculty activities through organizational systems, such as those that determine promotional policies and general resource allocation. Accordingly, leaders (e.g., department chairs, deans, presidents) play a key role in assigning value to and maintaining the research mission, which includes research didactics and activity within training programs. Therefore, the committee believes the following recommendation is critical to research training in psychiatry:

Recommendation 4.1. The broad psychiatry community should work more aggressively to encourage uni-

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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versity presidents, deans and hospital chief executive officers to give greater priority to the advancement of mental health through investments in leadership, faculty, and infrastructure for research and research training in psychiatry departments.

Although this recommendation applies equally to most branches of medical research, psychiatric research is arguably of particular importance in this regard. This is the case because current opportunities in brain and behavioral research are so great (see Chapter 1), and because mental illness is the object of considerable stigma that appears to have the dual effects of inhibiting efficient health care delivery (e.g., getting patients to the doctor), and impeding full reimbursement for rendered mental health services. The Surgeon General’s Report on Mental Health demonstrates as well as any document the relative importance of mental health; the ways in which the brain and behavioral sciences have advanced in recent years and the relevance of future advances to overall health; and the extent to which deeply engrained stigma works against equitable funding for mental health care—inequities that adversely affect research advances, which are partially subsidized by clinical revenues (DHHS, 1999).

Accordingly, medical administrators should be aggressively encouraged to invest in expanding research training in psychiatry as a first step to at least bring psychiatrists on par with the research efforts of many other medical specialists (e.g., subspecialties of internal medicine, neurology). Department chairs and other leaders can promote psychiatric research by developing and financing a long-term business plan that considers the monetary, marketing, and societal benefits likely to result from mental health research. Institutional executives need to be encouraged to invest in these plans by utilizing reasonable portions of their general funds (e.g., IME, dean’s tax, endowments) and by frequently including psychiatric research agendas in fund-raising efforts. At the same time, these leaders (especially those in psychiatry) should educate medical students and residents regarding the extraordinary intellectual ventures that accompany research in psychiatry. To the extent that such education and promotion efforts are already occurring, it is the committee’s sense that they need to be expanded if any real gains are to be made in the number of psychiatry trainees tracking to research careers.

One of the most intensive forms of leadership is mentoring. Mentoring is probably the ingredient cited most frequently as necessary for effective research training. The shortage of mentors is also a commonly noted barrier to effective research training. Accordingly, the committee believes that

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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financial incentives may be important to encourage more senior researchers, particularly at small institutions, to enter the mentoring pool. Accordingly, the committee makes the following recommendation:

Recommendation 4.2. Academic institutions and their psychiatry residency training programs should reward the involvement of patient-oriented research faculty in the residency training process. The National Institute of Mental Health should take the lead in identifying funding mechanisms to support such incentives.

This recommendation targets in particular smaller institutions with limited resources to offer a broad range of research experiences to and mentors for their trainees. Trainees in well-established programs are more likely to “pay for themselves” by extending the productivity of the mentor, and supplements to existing grants can be used to cover some of the costs associated with the trainees’ work. At less resource-intensive institutions, however, prospective trainees will likely be less familiar with research methods so that mentoring will require a greater investment of time with a potentially lower return in terms of trainee productivity. In these contexts, the committee encourages mechanisms to finance mentoring, with the provision that grant renewal would depend on the research success of the mentor’s past trainees. As an alternative to on-site mentoring, a remote system of mentoring might be devised to give both faculty and trainees the opportunity to be matched with individuals having similar interests outside of their institution. Furthermore, such a network might be sustained by offering senior mentors consulting fees or other remunerative support (e.g., travel, equipment) for their expertise and time.

In addition to issues related to institutional leadership and mentoring, this chapter has reviewed clinical research training programs generally and several psychiatry residency programs with regard to research training. The programs reviewed are highly variable. For example, nonpsychiatry training includes clinical research programs that range from 1-year certificates to multiyear programs culminating with a Ph.D. Although this range appears to be geared in part to the broad range of applicants, an AAMC task force concluded that program variability reflects imprecision regarding the formal constitution of clinical research training. Research training in psychiatric residency is also variable. Nevertheless, common best practices are apparent from reviewing existing programs and published descriptions. Most programs offer research training in the latter years of residency, and even the most research-intensive in-

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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stitutions route their research-oriented graduates toward additional training, usually in the form of a fellowship. Hands-on activity in residency is encouraged when resources and mentoring are available. Key course subject matter includes epidemiology, grant and manuscript writing, design of clinical trials, and research ethics.

Unfortunately, little has been done to integrate research training into all or even most of the residency years. Additionally, existing curricula are not typically validated by careful long-term follow-up studies to determine whether trainees actually were encouraged to move into patient-oriented research careers, or toward more evidence-based practice methods. Therefore, the committee makes the following recommendation:

Recommendation 4.3. The National Institute of Mental Health, foundations, and other funding agencies should provide resources to support efforts to create competency-based curricula for research literacy and more comprehensive research training in psychiatry that are applicable across the spectrum of adult (general) and child and adolescent residency training programs. Supported curriculum development efforts should include plans for educating faculty to deliver each new curriculum, as well as plans for evaluating each curriculum’s success in training individuals to competency and in recruiting and training successful researchers.

On the federal level, the K30 mechanism is an obvious means of supporting some curriculum development, although it does not have provisions for stipend support and is rarely utilized by medical residents. The AACAP research pathways are, to the committee’s knowledge, among the best models generated to date for creating and evaluating an exportable model for training psychiatrist-researchers, in this case targeting those in child and adolescent psychiatry. Such efforts should be extended to various other settings, including resource-poor departments and those that emphasize a given subspecialty of psychiatric practice (e.g., psychotherapy, addiction, pain management). These curricula should be aimed at sparking residents’ interest in a lifelong career in patient-oriented research without interfering with core clinical training. The principal aim of this recommendation, however, is to ensure that all residents are adequately introduced to the concepts of research and that research training is not merely an afterthought to residency education. Thus the recommendation is focused on ensuring a foundation in the

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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residency curriculum for patient-oriented research efforts. Even residents who intend to become clinicians should be introduced to the concepts and findings of patient-oriented research as a necessary complement to their clinical training. Curricula should be developed using established educational principles; it is especially important to include evaluation phases to verify the utility of the curricula in the training of patient-oriented psychiatrist-researchers and evidence-based practitioners (Sheets and Anderson, 1991). Novel ways to integrate research training into the residency experience for future clinicians and the next generation of independent investigators should also be considered. For example, Duke University is currently experimenting with a program that introduces research activity in PGY1 rather than waiting until later in the residency (list serve communication,29 G. Thrall, Duke University, January 12, 2003).

With regard to curriculum development, the committee believes that, since psychiatric training programs vary considerably in terms of size and local expertise, they should be viewed along a hierarchical research training continuum that ranges from those providing only research literacy to those training large numbers of patient-oriented psychiatrist-researchers. The committee proposes such a continuum in Table 4-3 (see page 131). An important feature of this continuum is the detail it provides about program components (e.g., longitudinal participation in research) and the corresponding department infrastructure (e.g., mentors and existing grants) necessary to achieve various levels of research training.

The schema represented in Table 4-3 shows how individual programs can consider their current infrastructure and build on their clinical and research strengths to enhance research training. For example, the presence of a large substance abuse clinic could be used as the foundation for a grant application to establish a research or research training effort in substance abuse, thereby advancing the program along the research training continuum. The continuum additionally is intended as a tool that can be used to implement the following recommendation:

Recommendation 4.4. The National Institute of Mental Health should support those departments that are poised to improve their residency-based research training to achieve measurable increases in patient-oriented research careers among their trainees. Support for such programs should include funds to:

29  

The list serve is maintained by the AADPRT.

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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  • Hire faculty and staff dedicated to research and research training efforts.

  • Acquire equipment and enhance facilities for research training.

  • Initiate pilot and/or short-term research activities for residents.

  • Educate adult and child and adolescent residency training directors and other faculty in how to promote and guide research career planning.

This recommendation aims to encourage NIMH to enhance the resources and environment of programs that can realistically advance their training efforts to the next level on the research continuum set forth in Table 4-3. A request for applications would best call for proposals from across the continuum, with the aim of funding a few programs at each of the three delineated levels (i.e., purely clinical, moderate research training, superior research training). Review committees for such grants would be instructed to rank applications on the basis of each program’s ability to demonstrate a plan for moving to and sustaining a higher lever of research training. At the bottom end of the continuum, programs would be expected to instill research literacy in their residents. Programs would also be expected to encourage their residents to transfer to other institutions (after 3-years of training) and aim for research fellowships to optimize their research training; for weaker programs, some altruism would be required if they did not have the local infrastructure to support a promising trainee.

Regarding the details of this recommendation, the first three bullets listed are linked quite directly to developing a research infrastructure. NIH or other agency grants—similar to the General Clinical Research Center or Biomedical Research Infrastructure Network grants—might be useful to this end. The expired Research Infrastructure Support Program (RISP), which still exists to help minority-based programs develop a foundation (see Chapter 5), is clearly a direct model for what is implied by this recommendation. The RISP was “…designed to enable institutions with relatively small but viable research programs…to develop into significantly stronger…research settings” (NIMH, 1994:2). That mechanism included possible support for: salaries, research training for junior investigators, and research instruments/equipment. One current RISP program announcement calls for applications for the funding of mental health services research at primarily clinical facilities. An important component of that announcement is that small programs are encouraged

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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Table 4-3 Continuum of Residency-Based Research Training

 

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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to develop direct collaborations with research-intensive institutions (NIMH, 2000c). This and other similar programs should be developed to improve research education at psychiatry training facilities.

With regard to bullet number 3 under recommendation 4.4, pilot or short-term funding could be utilized opportunistically by departments to facilitate the inclusion of more residents in research training. This is the case because residency is typically a career phase that permits limited and transient opportunities for the pursuit of nonclinical interests. A modest, but available pool of pilot funding might be used to support one or more training slots or other research-related resources to accommodate qualified and motivated residents.

The final item listed under recommendation 4.4 addresses the need to provide training directors and faculty with adequate instruction in guiding and nurturing potential researchers. Models at NIMH already exist in the form of seminars for K awardees (Tuma et al., 1987). Similar “retreats” for residency training directors and/or vice chairs of research could facilitate the flow of information on research training grants and other relevant matters to those most responsible for training residents. This recommendation also encourages the expansion and utilization of other means of information dissemination. These mechanisms include web-based resources, such as the NIH K Kiosk, which allows one to search and review various mentored career awards (NIH, 2003e). They further include on-line tutorials, such as one that currently exists on protecting the rights of research subjects (NIH, 2003f).

Suggested Citation:"4 Institutional Factors." Institute of Medicine. 2003. Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC: The National Academies Press. doi: 10.17226/10823.
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The number of psychiatric researchers does not seem to be keeping pace with the needs and opportunities that exist in brain and behavioral medicine. An Institute of Medicine committee conducted a broad review of the state of patient-oriented research training in the context of the psychiatry residency and considered the obstacles to such training and strategies for overcoming those obstacles. Careful consideration was given to the demands of clinical training. The committee concluded that barriers to research training span three categories: regulatory, institutional, and personal factors. Recommendations to address these issues are presented in the committee’s report, including calling for research literacy requirements and research training curricula tailored to psychiatry residency programs of various sizes. The roles of senior investigators and departmental leadership are emphasized in the report, as is the importance of longitudinal training (e.g., from medical school through residency and fellowship). As there appears to be great interest among numerous stakeholders and a need for better tracking data, an overarching recommendation calls for the establishment of a national body to coordinate and evaluate the progress of research training in psychiatry.

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