Residency Reforms Could Reverse Dearth of Researchers

Requiring psychiatry residents to become proficient in patient-oriented research, even if this means a reduction in clinical requirements, should be one element of a multipronged strategy to reverse a severe shortage of psychiatric researchers, according to a long-awaited report from the Institute of Medicine (IOM).

The report, “Research Training in Psychiatry Training: Strategies for Reform,” arose from concerns of National Institute of Mental Health (NIMH) officials that in an era when scientific knowledge about brain and behavior is exploding, the number of psychiatrist researchers who can translate these discoveries into clinical practice is “not keeping pace with the unparalleled needs that exist” in psychiatry.

NIMH asked the IOM to study the problem, focusing on the goals of psychiatry residencies, characteristics of successful research training programs, obstacles to producing more psychiatry researchers, and ways to overcome those obstacles.

The 12-member IOM committee was chaired by Thomas Boat, M.D., chair of pediatrics at the University of Cincinnati, who led a similar effort to include more research training in pediatric residencies. The committee included six psychiatrists. One of those psychiatrists, APA President-elect Michelle Riba, M.D., commented that the report comes at “a critical time” in psychiatry. NIMH’s decision to request the report was, she said, “a bold step” toward ensuring a healthy future for psychiatric research.

The committee concluded that the factors keeping future psychiatrists from training as researchers fall into three categories: regulatory, institutional, and personal. And “cutting across these factors are the ubiquitous and overlapping issues of time and money and the competing demands of patient-care activities.”

As for regulatory factors hindering research career development, the report noted that changes are needed in the minimum standards set by the Psychiatry Residency Review Committee (RRC) for program accreditation. In what will likely be a controversial recommendation, it calls for the RRC to reduce its clinical requirements so residents can fit in research-training electives.

“For example, the psychotherapy requirement, which includes the achievement of competency in five broad areas, could be reduced to knowledge in those five areas and competency in a subset,” the report suggested. Also, the traditional nine-month inpatient service “could be reduced to six months to allow time for other experiences.”

The report also urged the RRC and American Board of Psychiatry and Neurology (ABPN) to make board-certification requirements “more flexible” so research training can occur during residency. One example would be to allow residents who complete and prove competency in core requirements to spend more time pursuing research training.

In addition, the RRC and ABPN should make research literacy “a core competency of residency in adult and child and adolescent psychiatry.” The latter field, it pointed out, is especially desperate for new researchers.

As far as finding a reliable source of funding, the report stated that since research is rarely “considered part of core residency training. . . , the broad psychiatry community should work more aggressively to encourage university presidents, deans, and hospital chief executive officers to give greater priority” to advancing mental health through a greater investment in research-oriented faculty and psychiatry departments’ research training infrastructure.

The report pointed out that mentoring is probably the most crucial element in a successful research training program, and more incentives need to be found to “reward the involvement of patient-oriented research faculty” in residency training. It called on NIMH to “take the lead in identifying funding mechanisms to support such incentives.” Mentoring is such an important ingredient in the research-training stew that the IOM committee suggested that when in smaller programs “on-site mentoring is not possible, a remote network (for example, via the Internet) might be developed” to ensure that psychiatry residents have the chance to receive guidance from an experienced researcher.

Compensation a Key Obstacle

Not surprisingly, salary levels and other money matters are critical considerations for psychiatry residents contemplating research careers and must be increased in the field to attract the top medical students and residents, the IOM committee pointed out. “Furthermore, new physicians are understandably anxious about the challenges involved in securing long-term research funding and the workload associated with a research career.”

Researchers have written extensively about these discouragement-producing conclusions over the last few years, and the committee is concerned that while there is some truth to them, “they may overshadow the many positive aspects of a research career.” To counter these negative perceptions, the committee urged individuals and institutions to “strongly convey to trainees the benefits (professional and societal) associated with patient-oriented research in psychiatry.” Among the vehicles for accomplishing this are student interest groups and summer research opportunities.

The committee also emphasized the need to increase the numbers of women in psychiatry research careers and suggested that this could be achieved through “increasing part-time training and job-sharing opportunities, developing a critical mass of female role models and mentors, working with institutions to improve day care programs, . . . and educating women about the time flexibility of research careers.”

Minorities and international medical graduates were also on the radar screen of IOM committee members. They recommended, for example, that psychiatry training programs could encourage minority psychiatrists by recruiting minority faculty to serve as research mentors and pursuing funding from NIMH and other agencies that target minority-oriented programs.

To set their multiple recommendations in motion, the IOM committee is urging NIMH to “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 integration of research into psychiatric residency and monitor outcomes of efforts to do so.”

What Will Response Be?

IOM committee members are not under the illusion that all of their recommendations will be met with enthusiasm, but they hope that the report will, at minimum, raise awareness among stakeholder organizations.

“I envision that reactions will be mixed,” committee member Joel Yager, M.D., told Psychiatric News. “Some, perhaps most, training directors might experience the request to add flexibility to clinical training requirements as liberating. Others might be concerned that they may no longer have strict rules to back up administrative decision about how much time various rotations should entail.”

He added, “I don’t believe the field will respond with one voice, but I do think that a significant number of strong opinion leaders will help lead the way.” Yager is a professor of psychiatry and vice chair for education at the University of New Mexico and a director of the American Psychiatric Institute for Research and Education.

Riba believes that residency training directors “will be very receptive” to the recommendations and will appreciate the opportunity to work with the RRC, NIMH, and ABPN “to reframe the education process” so it can produce more researchers.

One danger of maintaining the status quo, Yager said, is the possible erosion of NIH’s ability “to conduct impartial research on important problems of core concern to psychiatric practice.” This would aggravate the perception among some in the field that “too much clinical research relies on industry sponsorship and that an insufficient amount of contemporary research undergoes the careful vetting and scrutiny required through the NIH processes.”

Key to achieving the kind of result the committee hopes its report will foster, Riba said, is “a coordination of effort. I hope that NIMH and APA will help forge a broad coalition of stakeholders in this effort.”

In addition to Riba and Yager, the psychiatrists on the IOM committee were William Bunney, M.D., Gabrielle Carlson, M.D., William Lawson, M.D., and James Hudziak, M.D.

The report is not available online. A print version can be ordered on the Web at www.nap.edu/catalog/10823.html. ▪