In 2003, the Institute of Medicine (IOM) drew attention to the critical national shortage of psychiatrist-researchers (1, 2). This report identified significant regulatory, institutional, and personal barriers to incorporating research training and related experiences into psychiatry residency. Among the IOM recommendations was the creation of competency-based curricula to promote research training during psychiatry residency as one means of addressing this critical shortage of psychiatrist-researchers at the institutional level.
Various approaches designed to promote the development of psychiatrist-researchers during general psychiatry (GP) residency have been described. One approach, typified by the University of Pittsburgh and the Medical University of South Carolina, involves the creation of research tracks (3, 4). Residents are selected according to their interests, qualifications, and perceived potential to become successful psychiatrist-researchers. The course of training for these residents differs from their training cohort in that some clinical duties are reduced, without compromising training in required areas; and these duties are replaced with structured activities in clinical research. Research tracks of this sort require special funding for their operation.
Particular mention is warranted here for the recently-established Integrated Research Pathway in Child and Adolescent Psychiatry (IRP-CAP) (5). This approach integrates training in adult and child psychiatry, along with clinical research training, over a period of 5 to 6 years. This pathway affords programs considerable discretion and flexibility for how to blend these three training components over time for a select group of residents. Two model programs, the University of Colorado and Yale University, are currently operational. Given the recency of the IRP-CAP's establishment and the small number of programs that have implemented it so far, it is too early to assess the viability of this approach for producing substantial numbers of child psychiatrist-researchers, especially since intensive educational coordination and additional funding sources are required, which may ultimately limit its generalizability.
A second approach for promoting scholarship during GP residency is exemplified by the University of California, San Diego, and the Veterans Affairs South Central Mental Illness Research Education and Clinical Center, where periodic training in clinical research occurs via special, recurrent, educational activities, such as seminars, workshops, and institutes, during the course of residency training (6, 7). Here again, residents are selected to participate on the basis of their interests, qualifications, and perceived potential. These activities are intended to build research skills in an incremental fashion, through participation at key points over the course of residency training. Skills are reinforced with ongoing involvement in mentored clinical research projects. The organization and implementation of these special training events requires additional funding mechanisms, as well.
A third method, typified by the Beth Israel Medical Center in New York and the University of Arkansas for Medical Sciences, takes a more universal approach to promoting scholarship during residency training (8, 9). Here, programmatic characteristics apply to all residents, and all residents are expected to utilize available resources to engage in scholarly work with research mentors over the entire course of their training. It is understood that the degree of participation by residents at any given point in time is dependent on the clinical training requirements for that stage of residency; that is, residents in the third and fourth years of training are expected to devote more time to scholarly pursuits than those in the first two years of training. Unlike the first two approaches, this method for promoting scholarship during residency does not necessarily require special funding sources; although it is subject to the availability of faculty to give of their time and resources for the sake of promoting the scholarly development of residents.
With the exception of the IRP-CAP track (5), published accounts for how to promote scholarship during CAP residency are lacking. In order to promote scholarship during CAP residency, three important challenges must be confronted. First, programs must create conditions that sustain the scholarly productivity of academically-oriented residents with previous research and scholarly experiences during GP residency. Second, they must provide opportunities for new scholars to emerge during CAP residency. These goals must be accomplished despite the relatively short, 2-year, duration of CAP residency, and the many core clinical requirements that must be completed during that time. Finally, many CAP programs do not possess the resources for dedicated research tracks or for supporting special training events. This means that any methods for promoting scholarship during CAP residency must be accessible to a wide range of programs if they are to have broad applicability and impact.
In an attempt to address the critical need for psychiatrist-researchers, we proposed a model and related benchmarks for the developmental attainment of core research competencies, and we identified key programmatic ingredients necessary to promote the acquisition of research competency during GP residency (10). In the current contribution, we describe the application of our model to the promotion of scholarship during CAP residency. We report on the comparative impact on the scholarly productivity of 52 CAP residents, who spanned 10 graduating classes, from 2002 to 2011.
Children's Hospital Boston (CHB) has offered CAP training since 1953. As with other ACGME-accredited programs, residents are accepted with at least 3 years of postgraduate training in general psychiatry, and the duration of CAP training is 2 additional years. In 2006, we redesigned our training program so that residents could engage more readily in scholarly pursuits. We were guided by our model emphasizing five core ingredients for promoting development of research competency during residency training: Mentoring, Education, Experience, Time, and Support (MEETS) (10).
In order to support residents in their scholarly pursuits, academic mentors are assigned upon entering the program. Initially, assignments are made by the Training Director on the basis of residents’ existing interests and previous experiences. Mentors advise residents from the outset, so that when the second year arrives, and more discretionary time is available, they "hit the ground running" around the pursuit of their scholarly interests. Mentors from previous training experiences are retained whenever feasible and indicated.
Formal educational experiences were systematically introduced into the training program. We initiated an 8-month, weekly research literacy seminar in the second year of training for all residents. Residents who choose to go beyond this and to engage in mentored clinical research take mandatory training in the responsible conduct of clinical research provided by the Hospital’s Clinical Research Program (CRP), and they are encouraged to enroll in seminars on clinical research methods and biostatistics provided jointly and free of charge by the CRP and the Harvard Clinical Translational Science Center. This highlights the importance of collaborations to access resources in other departments within the hospital and university environments.
A key role of mentors is to arrange for residents’ involvement in a range of experiences designed to promote development of scholarship. This can take a variety of forms. Mentors may invite residents to participate in research projects and laboratory meetings as well as the preparation of papers, presentations, and posters. The goal is for the resident to gain exposure to all facets of investigation and scholarship, from research design to the completion of products. Mentors may also nominate residents for membership in professional organizations or for special fellowship awards, and they may assist residents in applying for their own funding to support new projects.
In our program, residents are not required to utilize their discretionary time in the second year to engage in research. They may pursue other interests, with mentoring, so long as those initiatives are related to furthering their education in child development and child and adolescent mental health. Clinical electives, ethics, government relations, and medical education are among the more commonly chosen pursuits in this regard.
We instituted structural changes in our program to provide time for scholarship during the second year of training. Originally, residents spent 6 months doing inpatient psychiatry during the first year of training and 6 months doing consultation–liaison (CL) psychiatry in the second year of training. Since hospital-based care is often incompatible with time for scholarly pursuits, we moved the CL rotation from the second to the first year and reduced the duration of this rotation and the inpatient rotation from 6 to 4 months. We moved required subspecialty rotations—addictions, developmental disorders, neurology, and school-based consultation—into the newly-created 4-month block in the first year of training. The net effect of these changes was to free up an average of 2 days per week throughout the second year of training.
Mentors and Divisions/Departments may provide additional support through sharing of available resources (e.g., research assistant time) for residents' projects. Our department provides access to biostatistical consultation, seed money for deserving projects, as well as travel support to professional meetings; and CHB provides several competitive awards designed to support residents' research projects.
For the purposes of this report, scholarly products met the following criteria: 1) Residents had to be first authors; 2) Products had to be specific to mental health; 3) Products must have been peer-reviewed; and 4) Products must have been generated during GP or CAP training. We specified these criteria because, other than the constraint of being generated during residency training, they constitute the currency upon which academic productivity and advancement depend. Products that were included in this report involved: 1) posters, presentations, symposia, workshops, clinical perspectives, etc., presented at national and international meetings such as AACAP, AADPRT, APA, APPA, ESCAP, IACAPAP, etc.; 2) chapters, reviews, and original research papers; 3) research fellowships, including DuPont-Warren, Fogarty, Kaplen, Livingston, Zinberg, etc.; 4) research grants; and 5) IRB-approved projects.
Of the 52 residents included in this analysis, 27 completed their training before implementation of the programmatic changes, graduating between 2002 and 2006, and 25 completed their training after implementation of the changes, graduating between 2007 and 2011. Table 1 summarizes our observations in relation to the first challenge: sustaining the scholarly productivity of CAP residents who come with previous experience from GP residency. The number of residents entering CAP training with previous scholarly experience was comparable in both cohorts: 8 of 27 (30%) before implementation of the changes, and 9 of 25 (36%) after the changes (χ2=0.041; NS). Of these, only 1 of 8 residents (12.5%) was productive during CAP residency before implementation of the changes, whereas 6 of 9 (67%) were productive after the changes.
Table 2 summarizes our observations in relation to the second challenge: creating opportunities for new scholars to emerge among those residents without any previous scholarly experience. Before implementation of the programmatic changes, this did not occur for any resident. After the changes, 4 of 16 residents (25%) engaged in scholarly pursuits that led to products of the sort previously defined.
Combining the findings from Table 1 and Table 2, before the programmatic changes, only 1 of 27 residents (3.7%) were actively involved in scholarly pursuits during CAP residency. After the changes, 10 of 25 residents (40%) were involved in scholarly pursuits. The attainments of these residents included three competitive research fellowships, one competitive research grant, four original research papers, four chapters and reviews, six research posters, and four symposia or workshops.
Finally, because past behavior is predictive of current and future behavior, we utilized logistic regression to predict scholarly productivity during CAP residency from scholarly productivity during GP residency and from CAP training cohort. We report the impact on scholarship during CAP residency for each main effect, taking into account the other effect. The likelihood that CAP residents would be involved in scholarly pursuits if they had engaged in similar experiences during GP residency was 7 times greater than if they had not been previously productive (odds ratio [OR]: 7.29; 95% confidence interval [CI]: 1.33–40.06; Wald χ2[1]=5.22; p<0.03). The likelihood that CAP residents would be involved in scholarly pursuits if they were in the cohort after the programmatic changes was 24 times greater than if they had trained before the changes occurred (OR: 23.97; 95% CI: 2.40–239.6; Wald χ2[1]=7.32; p<0.007). Since the OR estimate is an effect size, our experience indicates that the training cohort was the stronger of the two effects.
Promoting rigorous scholarly activity during psychiatry residency with the goal of developing psychiatrist-researchers is an endeavor that presents numerous challenges. Some of these challenges are magnified during CAP training because of the relatively short duration of the residency itself and the many competing interests that must be satisfied during training. A number of viable approaches for promoting scholarship have been identified for GP residency, and one integrated approach holds promise for CAP residency, as well. However, none of these approaches address the challenges of promoting scholarship during CAP residency in a universal way that does not presuppose special funding mechanisms.
In this contribution, we described a universal approach for promoting scholarship during CAP residency that led to a tenfold increase in scholarly productivity among residents. The changes we put in place were critical for sustaining the productivity of residents with previous scholarly experiences, as well as for promoting new scholarship among residents without such experience engaging in scholarly pursuits. Despite these promising findings, a number of important questions remain unanswered.
What is the ‘durability’ of this scholarly productivity beyond child psychiatry residency?
Why didn’t all residents with previous experience continue to be productive during CAP training? What were the factors that precluded their continuation of an academically-oriented career?
What is the impact on the clinical training of those residents who take on rigorous scholarly endeavors? None of the residents who engaged in scholarly pursuits experienced performance difficulties in their clinical training, according to our regular supervisory reviews. However, we did not formally assess the potential intangible costs of engaging in scholarly activities during clinical training.
We did not systematically inquire about perceived facilitators or barriers to success; such as the nature and quality of mentorship.
We did not examine differences in trajectories that may have arisen in relation to gender, ethnic-racial identification, AMG/IMG status, and whether or not residents fast-tracked into CAP, because resultant smaller cell sizes if participants were further characterized, would not have permitted meaningful comparisons.
Limitations notwithstanding, the universal aspects of our approach, as well as our collaboration with other departments within the hospital and university to extend the resources available to residents, may be of greatest interest to other training programs, since these features benefitted all residents, and helped overcome inherent resource limitations. Our experience and impressions to-date also suggest that Mentoring and Time are the sine qua non of this approach and are the ingredients with the greatest impact on residents’ success in developing as scholars.
In conclusion, our experience indicates that through careful conceptual and logistical planning, and marshaling of existing resources, it is possible to sustain the scholarly activity of academically-oriented residents during CAP residency and to promote the emergence of new child-psychiatrist scholars, despite the relatively short duration of the program and the clinical training requirements that must be fulfilled for graduation and certification.