In the context of this series, it is redundant to proclaim the remarkable opportunities in biomedical science, and psychiatric research in particular. Research in neuroscience and mental and addictive disorders rivals any other scientific field in excitement and possibility, as underscored by the recent awarding of the Nobel Prize in Medicine to Drs. Carlsson, Greengard, and Kandel. Moreover, scientific advances have been accompanied by significant expansion in funding: between 1984 and 1998, NIH research support to academic departments of psychiatry grew by more than 400%—more than twice the rate of medical schools overall. Psychiatry departments moved from being the tenth-ranked academic department to Number Two, behind internal medicine.
Capitalizing on these scientific opportunities will require filling the critical ongoing need for clinically trained investigators who can provide a bridge between basic and clinical sciences. The clinician—investigator, however, remains an "endangered species" throughout all of biomedicine (1—3). AAMC data indicate that the percentage of medical students who expect to be "exclusively or significantly" involved in research has declined over the past decade (15.8% to 9.5% for matriculates and 15.5% to 11.9% for graduates ). While models of research career development have been promulgated in psychiatry (4), these data present an even greater problem, given the drop in American medical graduates entering psychiatric residency over the past 10—15 years, with the number now hovering around 450—500 per year. Although these numbers are augmented by talented graduates of international medical schools, they still present a very small N and represent only the very beginning of a pipeline noted for extensive "leakage." A concerted multi-level effort is necessary to ensure that the structure, process, and content of training opportunities are adequate to produce a new generation of psychiatrist—investigators of sufficient size. To respond to the challenges, the field needs to undertake a series of specific strategies.
Psychiatric teaching in medical school and residency must provide a richer and more compelling base of current scientific information, transmitting the excitement of the science. It must expand to the undergraduate level as well, with efforts especially targeted at potential M.D./Ph.D. students. For example, more than twice as many M.D./Ph.D. graduates go into neurology as psychiatry, despite the fact that the psychiatry faculty base in medical schools is vastly larger than neurology's.
Upgrading scientific teaching programs, while necessary, is not sufficient. There must be enhanced opportunities for undergraduate and medical students as well as residents and fellows to have intensive, longitudinal research experience in psychiatry laboratories and other research settings. Research tracks for residents should be expanded and formalized with the support and assistance of accrediting/ certifying bodies.
Successful outcomes generally require that training take place in a setting with sufficient scientific activity, where research is valued, and a critical mass of mentors and role models exist. Much like other areas of medicine, psychiatric research is narrowly concentrated in the small number of research-intensive departments that have this capacity. As such, major centers need to serve as national or regional resources where students and residents can obtain the kind of experiences described above. Furthermore, new technologies now make it possible to extend these opportunities through long-distance mentoring and instructional programs. Attracting and linking students to intensive research experiences needs to be done in a more systematic and formalized way, with necessary resources allocated.
Another essential element for success is a sufficient cadre of effective mentors, with the needed skills, interests, and resources. Unfortunately, there are not enough of these to go around. We need to be more expansive in our thinking regarding who can serve as a mentor for psychiatrists. We should be open to "mixed matches" with basic or behavioral scientists, pediatricians, neurologists, and so forth. In many cases, individuals will be benefited by a "pastiche" of mentors of various types, along with role models for success in both scientific and personal spheres. This approach may be an especially important strategy for women and minorities.
Although much research career success has proceeded serendipitously, we need to proceed in a more planful and systematic manner to provide a more predictable and doable (through highly competitive and by no means assured) career pathway and the tools to achieve success (5). Data have indicated that a 2- to 3-year period of research followed by at least an equal amount of protected junior-faculty research time is predictive of future success as an independent investigator (6). The NIH (and NIMH in particular) has shown foresight in developing Research Career Development awards (K-awards) and other mechanisms to assist in this process. However, given the narrowing (or nonexistent) margins of most clinical departments and the uncertainty and time-lags of the typical grant review process, most individuals will require some type of external bridging support during this critical period of time.
Finally, as the AAMC Task Force noted (3), systematic outcomes data on career choices and pathways are needed to identify optimal elements and models for research training and career development.