Over the last few decades, women have become a more significant and increasing portion of the psychiatric workforce. As Bickel reports in this special issue of Academic Psychiatry, women graduating from psychiatric residencies and working in university psychiatry departments now constitute 37% of the trainees and faculty (+1). Despite our increased numbers, however, we have not "naturally" progressed into positions of leadership and mentorship to the academic and research arenas of psychiatry. The national averages show that only 11% of women have progressed to full professor, compared with 31% of men in medicine in general. In psychiatry, the statistics are similarly disconcerting, 8% of women have achieved full professor compared with 26% of men. Bickel takes us to task as a profession when she writes "psychiatry… not realizing the full value of it’s women professionals may be considered both poor stewardship and bad business" (+1).

In 2001, the National Institute of Mental Health (NIMH), concerned that the decline in psychiatric-researchers and clinician-scientists would act as a significant barrier to its overall mission of reducing the burden of mental illness for the nation, commissioned the Institute of Medicine (IOM) to study the issues related to residency training that might be contributing to this decline (as Fenton, James, and Insel report in this issue [3]). Not surprisingly, in light of the ever increasing presence of women in the psychiatric work force (as noted above) the IOM report Research Training in Psychiatry Residency: Strategies for Reform identified issues of women in academic psychiatry and their lack of advancement as contributory to the decline of psychiatric-researchers. In his summary comments from the IOM report in this issue, Joel Yager notes that one of the obstacles identified by the IOM was "talents underutilized" (+2) Specifically he notes in his review of the recommendations, "Departments of psychiatry supported by the NIMH and other psychiatric organizations should provide leadership in recruiting and retaining more women for psychiatry research careers" (+2). Such efforts should include:

The newly formed NPTC (National Psychiatry Training Council), which was appointed by Tom Insel, M.D., Director of the NIMH, to implement the recommendations of the IOM report, has been charged to think boldly, with both eyes open toward implementation and development of recommendations that are "truly feasible" and that will bring about meaningful change. (PRR Summer 2004).

We know we make up a major portion of the psychiatric and medical work force; yet, have not advanced beyond the first stages of academic advancement. Often critical to this academic advancement is a successful career in research. And perhaps this in part explains why the proportion of women steadily decreases as we progress up the academic ladder from 46% of the instructors in medical schools, to 24% of the associate professors, to only 13% full professor ranks and 15% of the tenured faculty overall being women. Perhaps, even more discouraging, is that while the number of women in academia has increased steadily over the past 15 years, the growth of female full professors has grown only a single percent (10% to 11%). As Janet Bickel notes "complex systems do not change naturally" (+1). And Yager similarly notes, with regard to previous IOM reports on similar topics being ineffective, "The recommended solutions require highly involved bureaucratic interventions as well as money" (+2).

The issues have been well outlined as a need for more training in research, more mentors, and more flexibility. However, it’s not enough to identify what is needed. We have to make change happen and speak with actions not just words. For example, Bogan, in this issue, writes about the social pressure, as well as fiscal constraints, of pursuing maternity leave and the burden it places on fellow residents and the residency program. Yet, as she notes in closing, psychiatrists, physicians who specialize in improving the emotional and mental health of their patients, should begin to practice what they preach (+4). As a field, we need to bring up these "awkward" issues and address them, much as we assist our patients in facing their issues.

Policies can help to resolve some of these issues, but individual solutions, that work, can be models for the development of reasonable policies. I don’t think we can or should wait for global changes in policies on promotion and advancement in academia. We should work in our own departments and home institutions to force and facilitate change.

The articles in this issue of Academic Psychiatry also raise dilemmas around mentoring. However, it’s not enough to say women need female mentors. As has been highlighted, there is a dearth of women to serve as senior mentors. We can not, nor do we need to, rely simply on women to provide the needed mentorship. Instead the emphasis needs to change from having one mentor, to having an array of mentors and role models. It is extremely important to learn from our peers, as well as those above and below us in the academic hierarchy. For 10 years, I have helped oversee the Junior Investigator Colloquium at the APA, and often I feel the mentees in the small groups learn as much from each other as they do from the two mentors who chair the group. Another way to foster mentoring is to actually train the mentors as part of the curricula. The core concepts of mentoring are teaching and role modeling. If more attention is paid to teaching these skills more good mentors, male and female, will be available. As Bickel states in this issue, included in training on mentoring must be the discussion of issues of sexism and mental models of gender (+1). Who better than psychiatrists to begin to educate ourselves and our colleagues on the detriments of such stereotypes, and to model more appropriate and productive leadership and scholarly behavior?

Finally, each academic must take personal responsibility for the "mentoring" of their career, be they female or male, by developing a career plan. One would not embark on any trip without setting a destination and planning a route. Similarly, as a clinician-scientist, one would not pursue a research project without stating a hypothesis and developing a research plan. Similar consideration must be given to career path. Goals and objectives need to be set. Considerations should include not just career milestones and projects but, especially for women, when and if to have children and how to rear your children in ways that can be combined with an academic career and still allow one to feel fulfilled in both roles. Planning ahead does not guarantee that issues and conflicts will not arise, but coping with the expected and unexpected will be easier. One can not be afraid to set a 1, 2 and 3 year career plan. It can be modest or bold, and it does not need to be etched in stone. As in any good research plan, things will need to be changed and modified as new information and variables are considered. But having no plan, no roadmap, makes moving forward more difficult and makes it easier to get lost. Furthermore, a career plan can also help your colleagues and supervisors become part of the team helping you progress to your goals.

It’s time to stop waiting for global solutions and, instead, bring the solutions on step by step, even if some of those steps are unnatural. The best way to get a large change implemented is to show it works on a small scale. Here again, we can take a big lesson from research. Any large experimental undertaking begins with pilot data, results from a single patient, or a single probe of a single neuron. Then the hypothesis is expanded into a small sample of subjects or a different set of cells to see if it still applies, and then the larger study is proposed. As women take, and insist, on a more active role in academia we should look for the unique ways we can contribute. As Hirshbein notes in her article, women may be able to bring unique solutions to existing problems since they have been largely outside the academic inner circle up to now. As Bickel noted, "Improvements to complex systems do not occur naturally," (+1). Thus, I propose it is time for women to take some "unnatural steps" to change and broaden our roles in academic psychiatry.