There is a dearth of excited, committed, well-trained clinical investigators in psychiatry. This is despite a rapid growth in the scientific foundations of the field over the past 20—30 years. It is also despite substantial improvements in research methods and funding. All areas of psychiatric clinical investigation are in need of researchers, areas including, but not limited to, methods development, population epidemiology, clinical epidemiology, clinical genetics, brain imaging, clinical psychopharmacology, clinical trials, and outcomes research. Barriers to the recruitment of clinical investigators have been discussed by many publications, roundtables, and meetings; these barriers include the complexities of psychiatry as a field, difficulties in quantifying and studying psychiatric disorders, intricate human-subjects issues, negative perceptions from other branches of medicine, and others.
Yet, a message that seems to come across over and over again is that the most opportune time to cultivate a future psychiatric clinical investigator is during residency. It is during this time that the psychiatrist-trainee is immersed in learning about psychiatry, taking care of patients, reading the literature, and attending teaching conferences, all the while interacting with senior psychiatrists and other teachers. This immersion is occurring in a variety of environments, but, more often than not, in an academic environment where research is happening alongside clinical care. The purpose of this essay is to reflect upon my own experience in psychiatric residency and on how it influenced my development as a clinical investigator. It is also to reflect upon the key elements that need to be in place during psychiatric residency in order to entice residents into clinical investigation.
I came to psychiatric residency at the Johns Hopkins Hospital having grown up the son of an academic psychiatrist. I attended medical school at Washington University during the chairmanship of Samuel B. Guze, M.D., at a time when medical students at Washington University received considerable exposure to medical psychiatry and psychiatric research. Having worked several summers during college and medical school in clinical epidemiologic studies of schizophrenia at a chronic-psychiatric hospital in Greece, I had already been involved in psychiatric research.
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Coherence, mentors, and culture.
I arrived at Johns Hopkins intending to immerse myself in learning how to be a psychiatrist and taking care of patients. From the very beginning, several aspects of the environment increasingly drew my attention to research. The department of psychiatry, under the leadership of Paul R. McHugh, M.D., had a coherent approach to the understanding and teaching of psychiatry, as articulated in his book with Phillip Slavney, M.D.,
The Perspectives of Psychiatry (
+1). This book made the understanding of clinical psychiatry straightforward. It also illuminated the field's research opportunities clearly and very enticingly.
As a resident, I frequently interacted with, and had as teachers, clinicians who were also active and excited researchers. I saw, through them, how few clinical decisions in psychiatry have an empirical foundation. I observed in these mentors the fulfillment derived from a research career. I learned a bit about the practical side of doing research and how it fit into their daily professional lives. For example, some of my attending physicians at the time had to do rounds with me on patients in the morning and afternoon while carrying on research careers in between. They were excellent clinicians and formidable investigators.
During psychiatric residency, original research regularly informed clinical care. As much as possible, treatment decisions were based on the empirical evidence. Dr. McHugh, in his weekly meetings with the residents, in "Service Rounds," regularly referred us to original research and highlighted how it was guiding our understanding and care of patients. Also, the other teaching activities I attended exposed me to the knowledge base, in the form of original research, underpinning psychiatry. Not only was research part of my everyday life and the care of my patients, but also the findings of research evidence were ultimately the rules by which most clinical questions were settled. Of course, the art of psychiatry continued to be practiced where research evidence was either absent or inconclusive. This only served to increase my interest in clinical research; I wanted to find more answers to the day-to-day problems I faced.
In addition to the environment within psychiatry, the overall culture at Johns Hopkins Medicine was such that clinical research took place alongside clinical care in every medical field. Multiple conferences were available, bringing research findings to the bedside, discussing research papers, teaching the essentials of research, or simply speculating about how to do the right study to answer this or that question. Clinical researchers were highly visible within the clinical community. Most were open to taking on residents as students and offering them the opportunity to do research, either full-time—some of my colleagues took time off from residency to do research—or part-time. In fact, while a resident, I was offered the opportunity to participate in research projects with several investigators. Some of this work led to publications. This atmosphere permeated the institution and was part of most professional activities, either actively or in the background.
As I progressed through residency, I became persuaded that I wanted to continue to further and apply my skills as a clinician. Also, I wanted to develop my career as a clinical investigator. I was excited by the need to find answers to the day-to-day questions and problems of clinical care. I had seen that it was interesting and fulfilling to have a career in clinical investigation in psychiatry. The "Perspectives" (
+1) approach brought coherence to psychiatry and guided the research effort in a logical fashion. Observing my teachers live as doctors and as researchers demystified clinical research and made it look real and practicable. I also saw both the fun and the disappointing sides of research, and I observed some of the struggles involved in building a clinical research career in psychiatry.
By the end of residency, it was clear from my experience that in order to further my clinical research career, I had to develop myself in four areas. These are best summarized as 1) methods training; 2) focus; 3) mentorship; and 4) practice. I needed formal training in the science of psychiatric clinical investigation, its foundations, its methods, and how it interacts with the other medical sciences. I needed a focus on which to devote my interest, a theme around which I would apply my understanding of the methods. Although I am a person of many interests as a clinician, psychiatrist, and physician, I needed to focus on one area. Eventually, I reconciled this with my other interests by recognizing that my focus would be the area of research for which I would become known, while "keeping a toe in" several additional areas.
Next, I needed mentorship. I needed a behind-the-scenes tutorial in the intricacies of being a clinical researcher. I needed a model, a guide, a sounding board to help deal with the politics, the networking, and the tough decisions that come up all too often in such a career. I needed somebody I could trust, who would be loyal to me and not take advantage of me, who would be "straight" with me and help me direct my strengths and manage my weaknesses. I realized that I might even need several mentors to further my growth. This revelation came out of my appreciation of the many facets of clinical investigation. I would have to collaborate with colleagues and professionals of many different backgrounds, each of whom had something special to teach.
Finally, I needed an opportunity to practice. I had had a chance to practice some research in college, medical school, and residency, but in every case, research had been peripheral to my main activity at the time. I needed protected time where research was the focus. I had to learn more about methods, develop a focus, and interact with mentors—and, through them, with collaborators. I needed time to test my wings and start extending them in the actual day-to-day activities of clinical research. I needed to practice how to do research in its many different forms, all the way from understanding a field, defining a clinical question, making a prediction, designing a study, implementing the research, and disseminating it at meetings and in papers. I also needed to comprehend "human subjects" issues and to learn how to fund—and sustain funding for—research. Recognizing that a research career itself is ultimately only as good as its initial foundations, I needed a minimum amount of time where I could work on spreading my wings. This was the fellowship.
I eventually chose to do a fellowship in psychiatric epidemiology. Concurrently, I pursued a Master of Health Science degree in clinical epidemiology. My goal was to immerse myself in areas of epidemiology that were as far apart from psychiatry as reasonable (and permitted by my mentors). This was my methods development: I wanted to master the methods of epidemiology per se and then apply them to my focus. I chose as a focus the study and treatment of mood and other psychiatric disturbances arising in people with neurologic disease (neuropsychiatry). My initial interest was in the mood disorders of HIV disease and AIDS. Later, my attention shifted to mood disorders in dementia, Alzheimer's disease, and other brain diseases. This focus was inspired by the trails blazed by Paul McHugh, M.D., Robert Robinson, M.D., Peter Rabins, M.D., and Marshall Folstein, M.D., and all of those who continue to serve as mentors in my development.
A decade later, as I reflect upon my experience during residency, I think there were several elements critical to enticing me into a research career. The coherence brought to psychiatry by the approach of McHugh and Slavney was probably the first step. This coherence suddenly made psychiatric problems both interesting and approachable. The relevance of clinical research to the day-to-day care of patients was brought home by the way in which research knowledge was applied to patient care and by the many open questions that persisted. Clinical research had a purpose and a direction. My mentors taught me how I could continue to be the clinician that I wanted to be, continue to hone my clinical skills, and combine these with an active research career. They were excited, interested, clear-thinking, and quite successful. They had already blazed the trails; all I had to do was to learn to walk those trails behind them and perhaps extend them a bit.
The culture and atmosphere of the Department of Psychiatry at Johns Hopkins, particularly in marrying research and clinical care, and the high morale within the residency, also promoted my excitement for clinical research. Furthermore, I was offered the opportunity to do research, albeit a few small projects, with careful guidance and mentorship. Research was fun, part of everyday clinical care, easy to understand, and now demystified.
Finally, while a resident, I learned what I did not know and what proficiencies I needed to develop further. I was deficient in my understanding of research methods. I did not have a focus. I needed to formalize my relationship with mentors; and I needed practice in being a researcher. My experience during psychiatric residency was instrumental in laying the foundations for later development as a clinical researcher in psychiatry.