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Edited by Michael T. Abrams, Kathleen M. Patchan, and Thomas F. Boat. Washington, D.C., National Academies Press, 2003, 272 pp., $42.00 (paper).
This excellent monograph merits a place on the must-read list of every psychiatrist concerned about the future of our specialty. It reflects the thoughtful analyses and conclusions of a study committee on ways of incorporating research into psychiatric residency training. This broadly based committee was established by the Institute of Medicine, a component of the National Academy of Sciences. To avoid parochialism, its members included a neurologist, a neuropathologist, a public health economist, a pediatrician, and a medical school dean, along with eight psychiatrists (one of whom was Michelle Riba, now President of APA); the committee was chaired by Thomas Boat, a distinguished professor of pediatrics and national leader in medical education. The study was supported by funds from the National Institute of Mental Health (NIMH).
The report grapples with a major dilemma in mental health research. Even though ours is an era of rapid advance in the neural and behavioral sciences, with ever more precise and revealing investigational techniques, and even though the epidemiologic sciences have highlighted the magnitude of the illness burden resulting from mental disorders as well as the sizable discrepancies between the need for care and the provision of care the world over, far too few young psychiatrists choose careers in clinical and translational research. The number may even be declining, despite both opportunity and need. The committee does not engage in special pleading for psychiatry as a profession as opposed to psychology or neuroscience. To the contrary, it recognizes that interdisciplinary contributions to mental health research are essential. At the end of the day, however, the translation of basic science discoveries into clinical treatments and the evaluation of trials to assess their effectiveness require research psychiatrists on the team. How is the gap between the burgeoning opportunities for research and the failure of psychiatric residents to enter research careers to be explained? More to the point, how can it be corrected?
The analysis presented in Research Training in Psychiatry Residency is rich and complex; a detailed critique is beyond a short essay. At the risk of oversimplification, I limit myself to a few major issues. The Committee identified three sets of factors that influence attitudes toward research during psychiatric residency training: regulatory, institutional, and personal (the last perhaps better labeled "socioeconomic").
The regulatory body that controls the content of residency training is the Psychiatry Residency Review Committee. The responsibility for certifying the competence of graduates rests with the American Board of Psychiatry and Neurology (ABPN). Residency Review Committee specifications for the psychiatric curriculum are too lengthy and too rigid to allow the flexibility that research opportunities demand. ABPN certification examinations do not probe research literacy. Both bodies give short shrift to the science of psychiatry. Residency Review Committee requirements should be modified to allow residents who can demonstrate competence early to short-track standard rotations, providing time to participate in research. Most graduates of residency programs will not (and should not) choose research careers, but training should provide every clinical psychiatrist with what the report terms "patient-oriented research literacy." The ABPN should evaluate applicants’ ability to assess the clinical literature critically, a skill that is key to maintaining competence in clinical practice once residency training is over. To increase the likelihood that the Residency Review Committee and the ABPN will modify their current positions, the committee urges the organizations that nominate members to both bodies (the American Medical Association and APA, for example) to include more than token representation of experienced psychiatric investigators.
At the institutional level, a major obstacle is the limited resources for research training in psychiatry. NIMH can take the lead in creating funding mechanisms to encourage research faculty to become involved in residency training by underwriting costs for the time devoted to teaching. Some departments have produced curricula for research literacy. Their protocols should be shared with other departments. As far as opportunities for participating in research are concerned, not all departments are equal. A few have extensive extramurally supported research programs and are therefore able to provide exciting research experiences for trainees. Others have limited research programs and few faculty able to serve as mentors. One method of bootstrapping for change is the sharing of training opportunities by interdepartmental consortia to provide "guest" research rotations in resource-rich departments. Another is for NIMH to provide special developmental grants for departments that are poised on the verge of moving ahead with patient-oriented research.
Major sources of personal problems are two harsh economic facts: 1) anticipated salaries for psychiatrists, whether academic or clinical, are near the bottom of the physician pay scale, and 2) young physicians who are about to start their families face the impact of paying back staggering loans while on meager fellowship stipends. There is no ready remedy for relative salary scales, but loan repayment schemes can lessen substantially the financial burden for trainees willing to commit themselves to multiyear research fellowship programs.
Didactic seminars and brief research experiences during residency training obviously do not suffice to produce competent researchers. Residency training in adult and child training must be followed by 3 years or more of research fellowships in preparation for academic careers. However, exposure to the intellectual stimulation and the excitement of actually participating in research will help to recruit young men and women into postdoctoral programs.
The most unusual and most provocative of the committee’s recommendations is its last:
The NIMH should take the lead in organizing a national body, including major stakeholders (e.g., patient groups, department chairs) and representatives of organizations in psychiatry, that will foster the integration of research into psychiatric residency and monitor outcomes of efforts to do so. This group should specifically collect and analyze relevant data, develop strategies to be put into practice, and measure the effectiveness of existing and novel approaches aimed at training patient-oriented researchers in psychiatry. The group should also have direct consultative authority with the Director of the NIMH and also should provide concise periodic reports to all interested stakeholders regarding its accomplishments and future goals.
This national body is intended to take the lead in developing methods to monitor research career choices through the systematic collection of data on residency program graduates. The Institute of Medicine committee had to base many of its judgments on expert consensus because of the paucity of existing information: there is no "evidence base" on the outcome of research training programs or on which methods are most effective at fostering career development. Reports are not autocatalytic. They need constituencies to be their advocates if recommendations are to be converted into actions. I put this book on the must-read list for psychiatrists so that those who agree with its recommendations for research training policy can become its advocates.
First steps have already been taken. Thomas Insel, Director of NIMH, has convened a National Council on Psychiatry Training with representation from every organization that has a stake and a voice in psychiatry residency research training. The National Council on Psychiatry Training faces contentious issues. Must every graduate be competent in delivering all five modes of psychotherapy, as mandated by the Residency Review Committee in 2001? What is the meaning of a requirement for competence in "psychodynamic psychotherapy" in the absence of an unequivocal definition of its content or strong evidence for its effectiveness? Are there commonalities in psychological treatments that cut across schools of thought? Is the focus on psychopharmacology in some programs so disproportionate that trainees learn little about psychotherapy of any kind? Does the pharmaceutical industry influence the content of training through financial largesse? Each of these questions raises red flags. The topics that the National Council on Psychiatry Training will address are fundamental to preparation for practice as well as research. Psychiatrists’ views should be represented in the debate. Achieving consensus will not be easy, but the challenge cannot be finessed.
Better ways of preventing and treating mental disorders are key to reducing the illness burden. Only systematic research, basic and translational, can lead to improved care. Our responsibility to our patients requires us to ensure that those we train have the skills and opportunities to participate in psychiatric research.
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