"Since responsible innovation and experimentation are essential to improving professional education, experimental projects along sound educational principles are encouraged."
—Accreditation Council for Graduate Medical Education, 2006 (
1)
There is a dearth of child and adolescent psychiatrists to care for the nation’s children with serious mental health needs and their families (
2,
3). Additionally, policy makers and psychiatrists in academic, federal, and other strategic policy and advocacy settings have become increasingly concerned about the declining number of child and adolescent psychiatrists devoted to careers in patient-oriented research (
4,
5). The task of training physician-scientists in child and adolescent psychiatry has met with a double challenge: recruiting into a career in child and adolescent psychiatry and research. For the field of pediatric psychiatry, the paucity of physician-scientists has hampered the acquisition of a more complete understanding of the etiology and nature of disabling childhood disorders, and the provision of optimal prevention, early intervention, and safe and effective treatments for these disorders (
4,
6—
9).
The shortage of specialists in child and adolescent psychiatry is a long-standing problem. In 2001, the American Academy of Child and Adolescent Psychiatry (AACAP) resolved to make recruitment its top priority for the decade. Barriers to recruitment identified by the AACAP Task Force on Work Force Needs included inadequate exposure to child and adolescent psychiatry during medical school and psychiatry residency, increasing levels of educational debt, extended years of residency training, limited graduate medical education funding, lower clinical revenues under a managed care environment, and a devalued image of the profession (
2,
10—
13).
The challenge of recruitment into research careers plagues all fields of medicine. There has been an overall decrease in the percentage of U.S. physicians engaged in patient-oriented research, from 4.2% in 1984 to only 1.8% in 1999 (
14,
15). Reasons that have been posited for this decline include an increasing portion of students with a large academic debt, the extended period of training required to adequately prepare for a research career, and the perception by physicians that they may not be competitive with Ph.D.s for research funding (
16—
19). Attracting physicians into research careers in child and adolescent psychiatry is partially hampered by the types of individuals who have historically expressed an interest in the specialty. Early studies in the 1980s on career choice by Weissman and Bashook (
20) suggested that graduating medical students matching into psychiatry residencies who planned to pursue a career in child psychiatry tended to be predominantly interested in psychodynamics, pediatrics, and eclectic clinical approaches. Individuals interested in neuroscience and research careers often did not enter training in psychiatry with an articulated interest in child and adolescent psychiatry. It is unclear if this difference in orientation of physicians entering psychiatry still exists. If it does, it may be a substantial barrier to recruitment into research careers in pediatric psychiatry.
The urgency of the need for psychiatrist-researchers was addressed by the National Institute of Mental Health (NIMH) in 2001, which commissioned the Institute of Medicine, a subdivision of the nongovernmental National Academy of Sciences, to study the problem and offer recommendations to NIMH and the psychiatric profession as a whole. The Institute of Medicine committee gave a number of recommendations that are summarized in its 2003 report, entitled "Research Training in Psychiatry Residency: Strategies for Reform" (
21).
The overarching recommendation emerging from the Institute of Medicine report was for NIMH to organize a representative national body to foster the integration of research into psychiatric residency and monitor outcomes of these efforts. A direct product of this recommendation was the formation of the National Psychiatry Training Council, cochaired by Drs. John Greden and James Leckman. Its major focus was aimed at efforts to increase the training of psychiatrists who can conduct clinical and translational investigation and to improve research literacy of all graduating psychiatry residents. A central thrust of the charge of the Council was to develop a detailed vision for reforming psychiatric residency training to include more flexible core training requirements designed to ensure clinical competency while fostering earlier specialization and in-depth training in areas of research. The Model Programs Task Force, cochaired by Drs. James Leckman and Michael Ebert, investigated unique training models to enhance recruitment and optimize training of physician-scientists in psychiatry (
22).
In this article, we review child and adolescent psychiatry training tracks, with a special emphasis on providing for research training within the educational curriculum. We highlight two innovative integrated academic track programs that have emerged as a result of the Institute of Medicine impetus to optimize training of the next generation of physician-scientists. A detailed description of the training curriculum, methods of meeting all Accreditation Council of Graduate Medical Education (ACGME) training requirements, and a discussion of benefits and challenges of implementing an integrated psychiatry/child and adolescent psychiatry/research integrated training program are discussed.
+
Traditional Child and Adolescent Psychiatry Training
Training in child and adolescent psychiatry generally begins the fourth year after medical school, and follows postgraduate year 1 (PGY-1) (which includes at least 4 months of general medicine or pediatrics and 2 months of neurology) and two subsequent years of general psychiatry training. With recent revisions of the Residency Review Committee training requirements, child and adolescent psychiatry training may commence any time following graduation from medical school (
1). Some general psychiatry training programs have neuroscience or other research training tracks, integrating research training within the program, either in blocks or throughout the training cycle. For residents who choose these tracks, supports such as research mentors and the fact that clinical training requirements may be completed within 3 years (to allow the fourth year to be almost entirely elective for research) facilitate an academic career in psychiatry. Some programs have the flexibility to integrate child and adolescent experiences early in psychiatry training. Despite this flexibility, it is difficult for potential child and adolescent psychiatry researchers to gain, and/or to have the time in a full clinical schedule to utilize, child and adolescent psychiatry research mentorship and experience early in training. Many talented physician-scientists may find a fulfilling career niche within general psychiatry and forgo the further training in child and adolescent psychiatry, as the added 2 years of clinical training may disrupt an academic trajectory. Additionally, individuals who have participated in extensive research within their general psychiatry program frequently do not complete psychiatry training requirements until the end of PGY-4. Again, the added time constraint for child and adolescent psychiatry training may impede the pursuit of a career in academic child psychiatry. In general, research training for child and adolescent psychiatry occurs after the full 5 years of general psychiatry and child and adolescent psychiatry clinical training. By the time all clinical training is completed, family obligations, student debt, and lifestyle issues may deter prospective child and adolescent psychiatry researchers from obtaining this added training.
An innovative 5-year training sequence in pediatrics, general psychiatry, and child and adolescent psychiatry, better known as the "Triple Board," began as a pilot training experiment in 1986 under the leadership of John Schowalter and Norbert Enzer, and with the approval and support of the American Board of Psychiatry and Neurology (ABPN). It was approved nationwide as a combined residency in 1992 (
23). The Triple Board concept was to create an alternative pathway of training to become a child and adolescent psychiatrist that would combine pediatric, general psychiatry, and child and adolescent psychiatry and would allow a path less than that required in the conventional training sequence of 7 or 8 years. One of the goals of the combined training program was to create a nucleus of academically based child and adolescent psychiatrists who were trained and socialized as pediatricians and who could bridge the gap between the pediatric and the child and adolescent psychiatric communities. Additionally, it was hoped that this core of "Triple Boarders" could serve as a magnet in the academic environment to attract medical students to the specialty field of child and adolescent psychiatry. Follow-up suggests that this track has trained competent and successful clinicians and scientists, most of whom practice predominantly child and adolescent psychiatry, although often in a setting with medically compromised children (
24). Rotations and integration of the three specialties varies from program to program, but all programs provide 24 months of pediatrics, and 18 months each of general and child and adolescent psychiatry. There are presently 10 approved Triple Board training programs. The compressed clinical training in all three disciplines, however, often precludes participation in research training during the 5-year residency (
25).
+
Academic Integrated Training Tracks
In response to the Institute of Medicine report on the shortage of psychiatrist researchers, the Integrated Research Pathway in Child and Adolescent Psychiatry (IRPCAP) was developed from a remarkable collaboration between the National Institute of Mental Health (NIMH) National Psychiatry Training Council (NPTC) Models Program Task Force (authors JFL and ME as co-chairs), and the American Academy of Child and Adolescent Psychiatry (AACAP) task force on curricular reform in research training of child and adolescent psychiatrists (also chaired by author JFL with membership of RR, as well as Eugene Beresin, Steven Cuffe, John March, Hans Steiner, and Sidney Weissman). The IRPCAP was formed in 2002 by Marilyn Benoit, then President of AACAP (
21,
22). Modeled on the Triple Board program and the American Board of Internal Medicine’s Research Pathway, the IRPCAP meets all current ACGME requirements for both adult psychiatry and child and adolescent psychiatry. Two unique integrated research pathways programs have been implemented at the University of Colorado and then Yale University. Figure 1
compares current training pathways for clinical training plus intensive mentored research training.
The Integrated Research Pathway highlights four basic principles: early identity formation as a child and adolescent psychiatric researcher; the developmental continuity of training; concurrent clinical training in child and adolescent psychiatry; and individualization of mentoring, training, and "tooling" (learning the requisite knowledge and skills) opportunities to prepare the trainee for a research career. It was formally endorsed by the Executive Council of AACAP in the fall of 2004 and in the spring of 2005 by ABPN. The Yale Program takes two trainees annually, and currently has eight. The University of Colorado takes one or two annually, and currently has seven trainees. The University of Illinois at Chicago is in the process of implementing an integrated research training track, and others are investigating the feasibility of the model for their institutions.
+
The Yale University Albert J. Solnit Integrated Child and Adolescent Psychiatry Research Pathway
At Yale, the integrated training pathway was named to honor the memory of the late Albert J. Solnit, a pioneering child psychiatrist who served as the Director of the Yale Child Study Center from 1966 to 1983. Dr. Solnit, a neuroanatomist, pediatrician, child psychiatrist, and psychoanalyst provided international leadership for multidisciplinary programs of clinical and basic research, community outreach, and social policy. His work was inspired by the love of children and the goal of advancing the field in the best interest of children and families.
The Yale-Solnit integrated training program is funded by the generous support of a group of anonymous donors, start-up funds from the Yale University School of Medicine, a longstanding NIH-funded Institutional Research Training Program (T32MH018268-21) directed by one of the authors (JFL), and the recently funded NIMH Research Education Grant "Research Education for Future Physician-Scientists in Child Psychiatry" (R25 MH077823). Two authors (DS and AM) direct the child and adolescent clinical components of this program, in conjunction with the Director of Residency Training for the Department of Psychiatry at Yale (initially RB and subsequently PK) and the Director of Residency Training for Pediatrics (AF).
The program is designed to integrate training in research and clinical psychiatry for those physicians who are seriously pursuing careers in academic child and adolescent research. The program has a separate match number and a completely separate curriculum for trainees. Over 6 years, the Integrated Research Pathway provides core clinical training in both adult psychiatry and child and adolescent psychiatry, which would otherwise be available only as sequential training experiences in separate training programs. The program incorporates a predominantly pediatric internship year followed by a "Basic Skills" year, which allows for the identification of a research team and mentor, appropriate coursework and "tooling," as well as clinical experiences in evidence-based and long-term insight-oriented treatments. Research and clinical experiences with adults, children, adolescents, and families are integrated throughout the residency. Scheduled research time of at least 50% in the Basic Skills year (PGY-2), as well as in PGY-5 and PGY-6, qualifies trainees to apply for the NIH loan repayment program. Thus far, two of the Yale residents have been awarded this very significant financial benefit. Table 2
provides the 6-year curriculum for the Yale Child Study Center program (see http://info.med.yale.edu/chldstdy/training/adultchild.html for a detailed description).
+
The University of Colorado Integrated Research Pathway
The University of Colorado was the first institution to implement an Integrated Research Pathway. The program does not incorporate a separate match number, but has integrated research seminars, evidence-based treatments, and clinical research experiences into each of the training years on an individualized basis. Funding is available through graduate medical education training slots, clinical revenues, and an NIH-funded Institutional Research Training Program. Additionally, child and adolescent psychiatry experiences are optimized during general psychiatry training in each year of the program. The sixth training year is an optional year offered through the Developmental Psychobiology Research Group. The program is under the leadership of three authors (RR, AG, DC). Course structure includes seminars; case-based, evidence-based medicine seminars; live-patient dynamic group supervision; and individual supervision. Research-focused course content includes a first-year weekly research seminar designed to acquaint residents with the types of ongoing research available within the department; a second-year "Introduction to Research" seminar which discusses various methodological strategies; and a fourth-to-sixth year biweekly multi-institutional, multi-departmental seminar for all developmentally oriented mental illness researchers, which provides constructive review during the research project planning stages. Table 3
provides the 5- to 6-year curriculum for the Colorado program.
+
Ensuring Board Eligibility of Integrated Pathway Trainees
The integrated pathway programs have been designed to meet all current ACGME requirements for both adult psychiatry and child and adolescent psychiatry. All trainees must be notified during the application process if the integration will result in delay of eligibility for ABPN certification. The Yale pathway does not confer board eligibility until after PGY-6. Additionally, integration requires meticulous accounting of all of the ACGME training requirements to ensure that each is met. Although there is no separate accreditation of the program, the Yale program has been sufficiently unique in its overall integration that the ABPN requested a very specific monthly accounting of training, including a description of when and how each of the training requirements was met. Longitudinal treatment of children and adults from PGY-2 to PGY-6 is a core clinical experience of the Yale-Solnit residency. However, because this 10% clinical time is counted toward the longitudinal outpatient requirement, the 10% must be subtracted from other clinical experiences. For example, 2 months of consultation-liasion count for only 1.8 months after subtracting the 10% longitudinal treatment experience. This has made the Yale program accounting of requirements extremely complex.
The Colorado program has achieved the outpatient requirement in specified training years, and the training accounting has been more straightforward. Table 1
specifies the ACGME requirements and how the two Integrated Research Pathway in Child and Adolescent Psychiatry programs (Yale and Colorado) have fulfilled them. The ACGME requirements changed in July of 2007. The most noteworthy change for the integrated tracks is the decrease in minimum general psychiatry inpatient training, from 9 months to 6 months (with no more specialty inpatient experiences to be utilized for these 6 months). This may allow for further flexibility in the curriculum of the Integrated Research Pathways. The full accounting for ABPN approval of the curriculum for the Yale-Solnit Program is available on request from the first author.
+
The Residents’ Experience
A focus group of five of the six Yale-Solnit integrated program trainees was held to review aspects of satisfaction with the training program. The first issue discussed was that of peer group. Having a cohort of support with peers has been an issue of considerable discussion for small programs and in innovative pathways of training. The philosophy of the Yale-Solnit program has been one of "full inclusion." Thus, when residents are on a given rotation, they assume all of the responsibilities (including full call) of any other resident on that rotation. In general, the reported experience of the Yale-Solnit residents was one of being accepted and incorporated by peers in pediatrics, general psychiatry, child and adolescent psychiatry, and postdoctoral researchers during rotations with each of these groups. "You get to be part of multiple groups. They embrace you, but you do not go on to have the same shared experience." "Meeting people in multiple disciplines is a huge plus, and increases the range of experiences and relationships." "It mirrors what we do in the rest of our lives." The group felt that having at least one other integrated peer was important to the training experience, as it can potentially be isolating. Along these lines, the group felt that by now, with four cohorts up and running and a fifth about to be recruited, there is a legitimate sense of group cohesion and of a shared and unique training experience.
The trainees were very satisfied overall with the individualization which was inherent in the program. However, they felt that it was "not for everyone." The Yale-Solnit program requires highly motivated and self-directed individuals who come into the program with a good sense of their desired career trajectory. "You need to figure out what is important to you and your own development." "I’m not just a cog in a wheel. I am advancing myself and I have the autonomy to do it." "There is more emphasis on our training and less on just doing work." The research mentorship and the focus on career development by faculty was uniformly endorsed as a major positive of the integrated training model.
The major challenges of the program centered around how unique and new it was. "Logistics can sometimes be a problem. Some of the rotations do not quite know how to handle us. Even little things like lab coats and beepers can be a problem at first." The PGY-2 Basic Skills year allows for early research tooling and experience. On the other hand, "clinical continuity is broken," and this was identified by some as a disadvantage of this training model.
Trainee input into the design of the training model has been integral for the University of Colorado and the Yale-Solnit programs. The University of Colorado program initially utilized a separate match number and independent curriculum; however, as in the Yale-Solnit program, residents noted that the process was isolating. The University of Colorado thus switched the Integrated Research Pathways program back to a track within the more standard psychiatry programs and coordinated curriculums to allow greater interaction between the residency tracks. Isolation concerns decreased with this approach. The other major difficulty in the University of Colorado program occurs during the transition from the second to third year of the residency. By the end of the second year of training, University of Colorado trainees have experienced only 3 months of protected research time and several trainees have reported their clinical skills advancing more quickly than their research skills. This questioning of their own research capacity generally resolves by the middle of the third year of training.
Faculty comments about the integrated programs were solicited. The University of Colorado faculty have been highly positive in their comments about the program, not only because of benefits internal to the program but also because the program is having benefits throughout child psychiatry. "The program has inspired the faculty as well as the residents." "Even traditional child psychiatry residents are insisting that they work on scholarly projects and that they have an end product such as a scholarly publication." "Faculty are having to buy into scholarly activity as a primary outcome of the training mission." "This is not the child psychiatry training program of even a few years ago." The Yale faculty was similarly positive in comments, noting, "The residents are really superb!" "It is a pleasure to help train the next generation of leaders." "The Yale-Solnit integrated program sets the bar at a new level for recruitment, training, and innovative research collaboration between psychiatry and child and adolescent psychiatry."
The Integrated Research Pathway in Child and Adolescent Psychiatry (IRPCAP) was formulated by a collaboration between the National Institute of Mental Health (NIMH) National Psychiatry Training Council (NPTC) Models Program Task Force and the American Academy of Child and Adolescent Psychiatry (AACAP) task force on curricular reform, in response to the Institute of Medicine Report on the shortage of child and adolescent psychiatry physician-investigators. Currently, two programs nationally have well-formulated programs for this integration (University of Colorado and Yale University), and a number of others are considering taking the plunge.
Integration of child and adolescent psychiatry and research into a full training curriculum offers advantages for recruitment: a decrease in the risk of attrition of physician-scientists as it allows for early identity formation as a career investigator in child and adolescent psychiatry. Additional advantages are quality of applicants (Yale had 143 applications for two positions) and national recognition. This is a model training route to feed the pipeline.
Initiating an integrated pathway is not without challenges. Perhaps the largest challenge for training is funding. The Yale-Solnit program has a unique funding stream of donations, medical school support, and research grant funding. In general, getting an institutional training "slot" is advantageous for funding of clinical experiences. Ensuring clinical slot funding when research is integrated into clinical endeavors, and research grant funding when clinical training is integrated into research, is the ongoing art of program design. Additionally, the more completely research, child and adolescent psychiatry, and general psychiatry are integrated, the more essential it is that there be exquisitely detailed accounting of training requirements to ensure that each and every one is being met. Trainees need to be clearly informed if the integration may delay eligibility and/or complicate transfer to a more traditional training program. The research pathways are viable in institutions that have sufficient faculty in child and adolescent psychiatry and a solid research infrastructure. Faculty need to be motivated to take on this challenge, and research mentors must be available and enthusiastic about training.
The career trajectories of integrated research residents require evaluation to understand the effectiveness of the programs in promoting research careers. It is too early to know how the graduates of these programs will do on the ABPN examinations for psychiatry and child and adolescent psychiatry. It is also too early to know if the residents will pursue predominantly productive and funded research careers. The progress through residency and early career are areas currently being tracked.
There are many challenges to meet all existing requirements and to truly integrate research into psychiatry and child psychiatry training. The most recent Program Requirements for Residency Education in Psychiatry and Child and Adolescent Psychiatry of the ACGME (
1,
25) encourage unique model training initiatives.
"Since responsible innovation and experimentation are essential to improving professional education, experimental projects along sound educational principles are encouraged. Requests for experimentation or innovative projects that may deviate from the program requirements must be approved in advance by the Residency Review Committee, and must include educational rationale and method of evaluation. The sponsoring institution and program are jointly responsible for the quality of education offered to residents for the duration of such a project" (pp 23—24).
There is a solution to every problem; all you have to do is find it. It is hoped that the comparison and contrast of these integrated training pathways may inspire other centers to consider increased integration of child and adolescent psychiatry and research into their programs or initiation of an Integrated Research Pathway in Child and Adolescent Psychiatry to improve recruitment of the best and brightest into the field and to elevate the ranks of investigators in child and adolescent psychiatry. This is a unique opportunity for the field to consider model pilot training initiatives that will enhance recruitment into the field of child and adolescent psychiatry and feed the pipeline of physician-scientists to advance the art and science of patient care.
CAP=child and adolescent psychiatry